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/.ATLAS 

or 

SYPHILIS 

AND   THE 

VENEREAL  DISEASES 


INCLUDING 


A  BRIEF  TREATISE  ON   THE 

PATHOLOGY  AND  TREATMENT 


BY  1 

\ 

PROF.  DR.  FRANZ  MRACEK 

of  Vienna 


AUTHORIZED   TRANSLATION   FROM   THE  GERMAN 


EDITED   BY 


L.  BOLTON   BANGS,  M.D. 

Consulting  Surgeon  to  St.  Luke's  Hospital   and  the  City  Hospital,  New  York; 

late  Professor  of  Genito-Urinary  Surgery  and  Venereal  Diseases,  New 

York  Post-Graduate  Medical  School  and  Hospital 


With  71  Colored  Plates 


PHILADELPHIA 

W.  B.  SAUNDERS   &   COMPANY 

I  900 


Copyright,  1898, 
By  W.  B.  SAUNDERS. 


ELE0T9OTYPED  BY  PRESS  OF  W.   B.   SAUNDERS, 

VESTCOTT  &  THOMSON.    PHILADA.  PHILAOA. 


c.  S 


LIST  OF  ILLUSTRATIONS. 


Plate  1. 
Plate  2. 
Plate  3. 
Plate  4. 
Plate  5. 

Plate  6a. 
Plate  66. 
Plate  7. 
Plate  8. 
Plate  9. 
Plate  10. 
Plate  11. 
Plate  12. 
Plate  13. 

Plate  14. 

Plate  14a, 
Plate  15. 
Plate  16. 
Plate  17. 
Plate  18. 
Plate  19. 

Plate  20. 
Plate  21. 
Plate-s  22, 
Plate  24. 
Plate  24a. 
Plate  25. 
Plate  26. 


Sclerosis  in  the  coronary  sulcus  of  the  penis. 

Sclerosis  in  the  pubic  region. 

Sclerosis  on  the  anterior  surface  of  the  scrotum. 

Sclerosis  on  the  right  labium. 

Ambustiform  sclerosis  and   indurative  edema  of  the  left 

labium. 
Ulcerative  sclerosis  in  the  vaginal  portion  of  the  cervix. 
Sclerosis  in  the  vaginal  portion  of  the  cervix. 
Two  ulcerative  scleroses  on  the  os  uteri. 
Sclerosis  on  the  lower  lip. 
Sclerosis  at  the  right  angle  of  the  mouth. 
Sclerosis  of  the  tongue. 
Sclerosis  of  tlie  right  tonsil. 
Indurative  syphilitic  edema. 
Recent  macular  eruption  (roseola)  over  the  entire  surface  of 

the  body. 
Large  macules  mixed  with  papules,  scattered  over  the  entire 

body. 
(Dorsal  view.) 
Erythema  figuratum. 

Erythema  figuratum  (erytheme  circinee — Fournier). 
Syphilitic  papules  distributed  over  the  entire  body. 
Papulopustular  syphilide— Jaundice. 
Small,  aggregated  papules   (lichenoid    syphilide,  relapsing 

form). 
Papulosquamous  syphilide. 
Papular  orbicular  syphilide. 
23.     Irregularly  distributed  papular  syphilide. 
Leukoplasia  of  the  neck.     Papules  on  the  genitalia. 
(Front  view.) 

Flat,  glistening  papules  on  the  forehead  and  face. 
Syphilitic  alopecia  areolaris. 

7 


■JJj 


8  LIST  OF  ILLUSTRATIONS. 

Plate  26a.  Papules  on  the  hairy  scalp. 

Plate  27.    Small  pustules  on  the  face. 

Plates  28,  28a,  28i.     Pustular  sypliilide. 

Plates  29,  29«.     Proliferating  pustular  ulcers  (frambcsia  or  yaws)  on 

both  calves. 
Plate  30.     Psoriasis  syphilitica  plantaris. 
Plate  31a.  Eroded  papules  between  the  toes. 
Plate  31i.  Papules  and  fissures  between  the  toes. 
Plate  32.     Syphilitic  paronychia  of  both  hands. 
Plate  33.     Proliferating,  eroded  papules  of  diphtheritic  character. 
Plate  34.     Proliferating  papules. 
Plate  35.     Proliferating   papules  on  the  labia  majora,  iu  the  genito- 

crural  fold,  and  on  the  perineum  as  far  as  the  anus. 
Plate  36.     Proliferating  papules  on  the  labia  majora,  on  the  perineum, 

and  about  the  anus. 
Plate  37.     Hypertrophic  papules  and  folds  about  the  anus. 
Plate  38.     Old  annular  papules  that  have  begun  to  heal  in  the  ceuter. 
Plate  39.     Diphtheritic  papules  on  the  mucous  membrane  of  the  oa 

uteri  and  vagina. 
Plate  40.     Diphtheritic  pajjules  on  the  mucous  membrane  of  the  upper 

lij)  and  left  side  of  the  mouth. 
Plate  41a.  Infiltration  and  superficial  necrosis  of  the  mucosa  and  sub- 

mucosa  of  the  upper  lip. 
Plate  41i.  Ulcerating  papules  and  incipient  leukoplasia  of  the  tongue. 
Plate  42a.  Elevated,  coalescent  papules  on  the  hard  palate. 
Plate  426.  Leukoplasia  (psoriasis)  lingua". 
Plate  43a.  Condylomatous  iritis. 

Plate  436.  Gummatous  tarsitis  of  the  left  eye.     Trachoma. 
Plates  44,  45.     Syphilitic  frambesia  (yaws).     Syphilis  prsecox. 
Plates  46,  46a,  47.     tJummatous  ulcers  on  the   labia  majora,  the  pos- 
terior commissure,  the  right  labium  minus,  and 
the  vagina. 
Plate  48a.  Gummatous  ulcer  of  the  left  nipple. 
Plate  486.  Gumma  of  the  breast. 
Plate  49.    Syphilitic  rupia. 
Plates  50,  50a.    Serpiginous,  gummy  ulcers. 
Plate  51.     Serpiginous,  gummy  ulcers  of  the  right  calf. 
Plate  52.     Cutaneous  gumma  on  the  dorsum  of  the  foot.     Gumma  of 

the  pharynx. 
Plate  52a.  Ulcerative  gummata  of  the  pericranium. 
Plate  53.     Gumma  in  the  glands  of  the  neck,  with  destruction  of  the 

integument. 
Plates  54,  54a.     Gummatous  ulcers  of  the  skin  and  inguinal  glands. 


LIST  OF  ILLUSTRATIONS. 


Plate  55. 
Plate  56a. 
Plate  566. 
Plate  57. 
Plate  58. 
Plate  59. 
Plate  60a- 
Plate  61. 
Plate  62. 

Plate  63. 

Plate  64. 

Plate  65. 
Plate  66. 
Plate  67. 
Plate  68. 


Plate  69. 
Plate  70. 
Plate  .  1. 


Gummatous  disease  aud  uecrosis  of  the  soft  parts. 

Uestructiou  of  the  soft  palate  by  gummatous  ulceration. 

Gumma  ou  the  posterior  wall  of  the  pharyux. 

Gummatous  glossitis. 

Papulopustular  exanthema.     Hereditary  syphilis. 

Papulovesicopustular  exanthema.     Hereditary  syphilis. 

c.     Hereditary  syphilis. 

Venereal  ulcers  on  the  foreskin  aud  ou  the  head  of  the  penis. 

Contagious,  coalescent  venereal  ulcers  on  the  skin  of  the 
penis.     Adenitis  of  the  right  inguinal  glands. 

Paraphimosis  from  venereal  ulcer  on  the  foreskin.  Inflam- 
matory edema.     Suppurative  adenitis  in  both  gioius. 

Suppurative  lymphangitis  of  the  dorsum  penis  (bubonulus 
Nisbethi),  with  uecrosis  of  the  integument. 

Abscess  of  the  left  gland  of  Bartholin. 

Gonorrhea.     Cavernitis. 

Condylomata  acuminata. 

Condylomata  acuminata  on  the  coronary  sulcus  and  on  the 
inner  layer  of  the  foreskin,  which  is  inflamed  and 
necrotic  along  the  left  border. 

Condylomata  acuminata  at  the  os  uteri. 

Subcutaneous  hemorrhage  into  the  skin  of  the  penis. 

MoUuscum  contagiosuni  (moniliforme  [bead-like]). 


EDITOR'S  PREFACE, 


Thoroughness  has  always  been  granted  as  one  of  the 
chief  attributes  of  German  teachers.  The  present  volume, 
in  the  opinion  of  the  editor,  shows  another  trait  no  less 
characteristic,  but  which  is  perhaps  not  so  generally  con- 
ceded. It  is  a  certain  strong  practical  sense  in  selecting 
the  material  and  presenting  it  in  the  form  best  fitted  to 
the  needs  of  those  for  whom  it  is  intended.  On  the  lat- 
ter point  the  author  has  defined  the  purpose  of  his  work 
in  his  preface.  Making  some  allowance  for  local  customs 
and  conditions,  especially  in  the  matter  of  treatment, 
the  book  will,  it  is  believed,  prove  a  thoroughly  practical 
manual  for  the  every-day  use  of  the  practising  physician. 

The  translator  has  endeavored  to  follow  the  German 
text  as  faithfully  as  possible,  and  has  ventured  to  depart 
from  the  original  only  when  the  needs  of  the  language  ap- 
peared to  justify  such  a  departure.  The  translation  will 
therefore  be  found  to  be  a  conscientious  reproduction  of  the 
author's  ideas  in  concise,  smooth,  and  graphic  phraseology. 

For  the  sake  of  convenience  the  names  of  drugs  and 
certain  technical  terms  have  been  made  to  conform  to  the 
current  English  expressions,  and  in  the  prescriptions  the 
equivalent  amounts  in  apothecary's  weight  have  been 
added  in  parentheses  after  the  number  of  grams. 

A  short  index  has  been  added,  which  is  to  be  regarded 
rather  as  a  supplement  to  the  table  of  contents  and  the 
list  of  illustrations. 


PREFACE, 


Ix  complying  witli  the  publisher's  request,  made  to  me 
two  years  ago,  to  prepare  an  Atlas  of  Venereal  and  Syph- 
ilitic Diseases,  I  have  endeavored  to  produce  a  book  which 
should  be  w^ithin  the  reach  of  a  wider  circle  of  readers, 
as  both  the  scope  and  the  cost  of  the  pictorial  works 
hitherto  published  on  the  subject  necessarily  restrict  their 
influence  to  a  comparatively  small  number.  To  carry  out 
this  plan  it  was  found  necessary  to  select  those  diseases 
which  are  of  the  most  frequent  occurrence  and  greatest 
practical  importance,  omitting  such  as  interest  only  the 
specialist.  The  same  principle  controlled  the  composition 
of  the  text.  The  clinical  material  is  drawn  chiefly  from 
my  ward  in  the  K.  K.  Rudolfsspital  in  Vienna.  I  have 
to  express  my  thanks  to  Dr.  Braun,  Director  of  the 
Northern  Austrian  Foundling  Asylum,  for  two  cases  of 
hereditary  syphilis;  to  (Prof)  Dr.  Bergmeister,  "Primar- 
arzt,"  for  two  cases  of  syphilitic  eye-disease,  and  to 
(Prof)  Dr.  E.  Lang  for  a  case  of  disease  of  the  hairy 
scalp. 

Mr.  Schraitson  mastered  the  difficult  problem  of  inter- 
preting and  reproducing  the  various  clinical  pictures  in 
an  amazingly  short  time,  and  has  turned  out  a  truly 
admirable  set  of  water-colors,  the  reproduction  of  which 
by  the  publishing  house  has  been  done  in  the  most 
exemplary  manner. 

13 


14  PREFACE. 

In  the  work  of  sifting  the  case-histories  and  preparing 
the  material  I  have  been  most  ably  and  zealously  aided 
by  my  assistant,  Dr.  Grosz. 

To  all  these  gentlemen  I  wish  to  express  my  hearty 
thanks,  and  I  trust  that  the  present  work  may  meet  with 
a  kind  reception  among  those  for  whom  it  is  intended. 

Dr.  MRACEK. 

Vienna,  November,  1897. 


CONTENTS. 


PAGE 

Introduction 1 

the  Primary  Stage  of  Acquired  Syphilis. 

Couditious  of  Infectiou 4 

Channels  of  Infection 5 

The  first  Phenomena  that  appear  after  Syphilitic  Infection      ...  7 

Swelling  of  Lymph-glands 10 

Phimosis  and  Paraphimosis      10 

The  Secondary  Stage  of  Syphilis. 

Prodromal  Symptoms  during  the  Eruptive  Period 11 

The  Syphilitic  Exanthemata 13 

The  Macular  Syphilide 13 

The  Papular  Syphilide 15 

The  Pustular  Syphilide 17 

Syphilides  with  Cutaneous  Hemorrhages 19 

Ahnormal  Color-changes 20 

Diseases  of  the  Hairy  Scalp 21 

Diseases  of  the  Palms  of  the  Hands,  Soles  of  the  Feet,  the  Fingers, 

and  the  Toes, 22 

Secondary  Syphilitic  Phenomena  in  the  Genitalia  and  ahout  the 

Anus 23 

Diseases  of  the  Buccal  Mucous  Memhrane     26 

The  Tertiary  Stage  of  Syphilis. 

Introduction     28 

Gumma  of  the  Skin  and  Subcutaneous  Cellular  Tissue 31 

Tertiary  Syphilis  of  the  Motor  Apparatus 35 

Tertiary  Syphilis  of  the  Lymphatic  Apparatus 38 

Tertiary  Syphilis  of  the  Digestive  Tract 41 

Tertiary  Syphilis  of  the  Respiratory  Tract 49 

Tertiary  Syphilis  of  the  Circulatory  System 51 

Tertiary  Syphilis  of  the  Genito-urinary  Apparatus 53 

Tertiary  Syphilis  of  the  Eye 57 

Tertiary  Syphilis  of  the  Central  Nervous  System 60 

15 


16  .     CONTENTS. 

PAGE 

Hereditary  Syphilis 64 

The  Treatment  of  Syphilis     72 

Primary  Forms        72 

Local  Treatment  of  the  Secondary  and  Tertiary  Lesions 75 

General  Treatment 79 

The  Care  of  the  Mouth  before  and  during  Mercurial  Treatment    .    81 

Mercurial  Treatment  of  Syphilis 82 

Use  of  the  lodids  in  Syphilis 86 

Medicinal  Woods 88 

Venereal  Ulcers. 

Complications :  Lymphangitis,  Adenitis     92 

Treatment  of  Venereal  Ulcers 96 

Gonorrhea. 

Gonorrhea  of  the  Genitalia 101 

Complications 104 

Condylomata  Acuminata 107 

Treatment  of  Gonorrhea  and  its  Complications 109 


PLATE   1. 
Sclerosis  in  the  Coronary  Sulcus  of  the  Penis. 

Present  Condition. — On  the  dorsal  aspect  of  the  neck  a 
sclerosis  measuring  about  1  cm.  in  diameter;  the  surface  is 
necrotic,  the  base  and  surrounding  tissue  moderately  infiltrated. 
Perceptible  swelling  in  the  inguinal  glands;  on  the  trunk  a 
pale,  slightly  raised  eruption. 

Sch.  J. ;  admitted  Nov.  24,  1895.  Says  he  had  his  last  coitus 
Oct.  4th ;  the  sore  on  the  penis  developed  four  weeks  later. 
Has  always  been  healthy. 


Tab.     1. 


LUk^AriSt  F.  ReUhhMd.  MUiuJicn 


PLATE  2. 
Sclerosis  in  the  Pubic  Region. 

Present  Condition. — In  the  pubic  region  there  is  a  sclerosis 
about  the  size  of  a  hazehiut  which  is  quite  deep ;  the  floor  is  cov- 
ered in  part  with  pus  and  in  part  with  pale  granulations ;  the 
edges  are  sharp,  tough  and  infiltrated,  and  surrounded  by  a  zone 
of  inflammation.  The  inguinal  glands  are  greatly  enlarged ;  the 
axillary  and  cervical,  only  moderately  so. 

M.  T.,  34  years  old,  works  in  a  gas-factory;  admitted  June  7, 
1896.  In  the  beginning  of  May  a  glowing  piece  of  coke  fell  on 
the  patient's  bare  breast ;  in  attempting  to  shake  it  out  of  his 
clothing  he  burnt  himself  in  the  pubic  region.  Two  weeks  later 
he  had  coitus.  He  had  no  suspicion  of  the  true  nature  of  his 
disease.  On  June  20th  a  dark -red,  papular  syphilide  appeared 
on  the  body. 

Local  treatment  and  twenty-five  inunctions  effected  a  cure. 


PLATE  3. 
Sclerosis  on  the  Anterior  Surface  of  the  Scrotum. 

Present  Condition. — On  the  scrotum,  below  the  angle 
formed  by  the  penis  (penoscrotal  angle),  is  seen  a  sclerosis  a 
little  larger  than  an  almond.  The  surface  is  ulcerated,  the  base 
and  edges  infiltrated.  The  rest  of  the  genital  region,  as  well  as 
the  skin  on  the  trunk  and  extremities,  is  covered  with  recent 
papules  as  large  as  lentils.  The  older  of  these  papules  already 
show  desquamation  on  the  surface. 

W.  A.,  28  years  old,  mail-driver;  admitted  Nov.  1, 1895.  The 
patient  says  he  paid  no  attention  to  the  sore  on  the  scrotum  at 
first.  It  began  to  be  more  noticeable  four  weeks  ago;  the  erup- 
tion appeared  only  six  days  ago. 

After  local  treatment  with  gray  plaster  and  a  course  of 
twenty-five  inunctions  the  sclerosis  healed  completely,  the  in- 
filtration at  the  base  softened,  and  the  eruption  disappeared. 
The  patient  was  discharged  on  Dec.  2d,  after  thirty -two  days' 
treatment. 


Tab.     3. 


vC-V« 


-ti* 


'^Mik' 


^''■y 


w 


^ 


PLATE  4. 
Sclerosis  on  the  Right  Labium  Majus. 

The  right  labium  majus  is  moderatel}'  swollen  and  edematous. 
On  the  external  surface  of  the  lowest  segment  there  is  a  hard 
lump  about  as  large  as  a  penny  ;  the  crater-like  center  is  covered 
with  pus  and  discharges  quite  freely. 

In  addition  to  the  sclerosis  described,  the  patient  exhibits 
a  macular  syphilide  on  the  trunk  and  a  lenticulo-papular  erup- 
tion on  the  thighs  and  nates.  The  inguinal,  as  well  as  the  cervi- 
cal and  axillary  lymph-glands  on  both  sides  of  the  body  are 
involved. 

K.  C,  20  years  old;  admitted  Aug.  16,  1896.  Her  first 
venereal  attack,  which  she  says  began  three  weeks  ago  (?). 

After  fifteen  inunctions  the  sclerosis  healed,  the  edema  dis- 
appeared, the  eruption  became  less  angry  (paler),  and  the  infil- 
tration about  the  site  of  the  sclerosis  as  well  as  the  glandular 
swelling  diminished. 


PLATE  5. 

Ambustiform  Sclerosis  and  Indurative  Edema  of  the  Left 
Labium  Majus. 

Present  Condition. — The  entire  left  labium  niajus  shows  a 
livid  discoloration  and  is  considerably  swollen  and  indurated. 
About  the  middle  is  an  ulcer  with  hemorrhagic  floor  and 
slightly  eroded  edges,  resembling  a  wound  made  by  a  red-hot 
instrument  (sclerosis  ambustiformis).  The  inguinal  glands, 
especially  on  the  left  side,  are  swollen,  and  the  axillary  and 
cervical  glands  slightly  enlarged.  Patient  had  been  suffering 
from  insomnia  for  a  week.  Later  in  the  course  of  the  disease 
a  roseola  appeared  on  the  trunk. 

H.  M.,  21  years  old,  cashier;  admitted  Oct.  13,  1896.  The 
patient  says  she  noticed  her  condition  only  a  week  ago.  Last 
coitus  seven  weeks  ago. 

After  the  use  of  inunctions  the  eruption  disappeared,  the 
glandular  swelling  diminished,  the  sclerosis  healed,  and  the 
indurative  edema  was  reduced  to  an  elastic  thickening  of  the 
labium. 


Tab.     5. 


■-i%''  "^^i. 


Z///j .  A/ist.  H  Reidihold.  Hiindien . 


PLATE    6a. 
Ulcerative  Sclerosis  in  the  Vaginal  Portion  of  tlie  Cervix. 

The  vaginal  segment  enlarged  as  a  whole ;  the  os  slightly  con- 
tracted by  scar-tissue.  On  the  anterior  lip,  close  to  the  os,  is  a 
slightly  raised  sclerosis,  the  floor  of  which  presents  a  diphther- 
itic appearance  and  is  marked  in  places  by  small  henaorrhages. 
On  palpation  a  lump  as  hard  as  cartilage  can  be  plainly  made 
out  in  the  vaginal  jjortion.  There  is  a  shallow  erosion  on  the 
posterior  lip. 

B.  A.,  22  years  old.  The  patient  has  given  birth  to  one  child. 
She  first  became  aware  of  her  disease  when  a  sclerosis,  similar 
to  the  one  described,  appeared  on  one  of  the  labia.  She  knows 
nothing  of  the  sclerosis  in  the  vaginal  portion.  Last  coitus 
seven  weeks  ago,  last  but  one  eighteen  months  ago. 

Later  in  the  course  of  the  disease  a  macular  syphilide  made 
its  appearance.  Liguinal,  cervical,  and  axillary  glands  enlarged. 

Inunction  treatment. 

The  sclerosis  was  excised  and  examined  under  the  micro- 
scope.^ 

See  Viertdjahrschrift  fiir  Demwiologie,  1881,  page  57  et  seq. 


PLATE   6b. 
Sclerosis  in  the  Vaginal  Portion  of  the  Cervix. 

Present  Condition. — Vagina  pale  and  distended ;  secretion 
scanty.  Cervix  large  and  cylindrical.  On  the  anterior  lip  is  a 
circular,  sharply  circumscribed  ulcer  about  as  large  as  a  penny, 
with  purulent  floor.  Surrounding  tissue  much  inflamed.  Glands 
palpable  everywhere. 

P.  C,  43  years  old,  prostitute;  admitted  April  15, 1896.  Says 
she  has  been  ill  six  days. 

Treatment.  —  White-precipitate  ointment.  Cicatrization 
May  4,  1896. 


Tab.     6. 


I.ith .  Atist  /:'  Reidilwld,  Miinchen.. 


PLATE   7. 
Two  Ulcerative  Scleroses  on  the  Os  Uteri. 

The  cervix  as  a  whole  is  swollen  and  edematous,  and  shows 
several  cicatricial  contractions,  the  result  of  former  confine- 
ments. On  symmetrical  areas  of  the  anterior  and  posterior  lips 
are  two  sharply  circumscribed  scleroses,  with  raised  edges  and 
purulent  floor.  The  surrounding  tissue  is  very  hard  to  the 
touch.  The  secretion  is  serous  in  character  and  not  particularly 
copious. 

G.  M.,  24  years  old.  The  patient  was  not  aware  of  her  dis- 
ease, but  came  to  be  treated  for  papules  in  the  vestibule.  In 
addition  to  the  sj^mptoms  described,  the  patient  had  a  slight 
macular  eruption  and  glandular  enlargement. 

Patient  was  subjected  to  inunctions. 


Tab. 


PLATE   8. 
Sclerosis  on  the  Lower  Lip. 

Present  Condition.— On  the  lower  lip,  to  the  right  of  the 
middle  line,  is  an  ulcer,  about  1.5  cm.  in  thickness,  the  center 
somewhat  depressed,  with  slightly  raised  edges.  There  is  some 
infiltration  and  the  ulcer  is  breaking  down. 

The  patient,  K.  M.,  21  years  old,  does  not  know  the  cause  of 
this  ulcer,  which  appeared  about  four  months  ago  and  has  been 
steadily  growing  larger.  The  only  other  symptom  is  swelling 
of  the  submaxillary  glands;  the  cervical,  axillary,  and  inguinal 
glands  are  also  enlarged;  the  genitalia  are  intact. 

The  ulcer  healed  after  the  application  of  gray  plaster  and 
about  thirty  inunctions. 


Tab.     8. 


:old,Miuichnii 


PLATE    0. 
Sclerosis  at  the  Right  Angle  of  the  Mouth. 

N.  P.,  29  years  old,  blacksmith;  admitted  Oct.  30,  1895. 
Eight  weeks  ago  the  ])atient  first  noticed  a  sore  at  the  right 
angle  of  the  mouth,  which  slowly  hut  steadily  increased  in  size. 
Five  weeks  ago  the  right  cheek  and  the  right  submaxillary 
region  l)egan  to  swell.  Tlie  patient  does  not  know  the  cause  of 
his  disease ;  but  he  says  that  at  the  time  it  began  there  was  a 
man  in  the  shop  where  he  works  who  was  suflering  from  a 
chancre.  For  the  past  two  weeks  he  has  had  severe  nocturnal 
headache. 

Present  Condition. — In  the  mucous  membrane  of  the  right 
angle  of  the  mouth  an  oval,  cup-shaped  ulcer,  over  h  cm.  long, 
covered  with  pus.  The  right  side  of  the  face  is  swollen.  The 
submental  and  submaxillary  lymph-glands  are  enormously  en- 
larged. The  other  lymph-glands  are  also  involved,  but  not  to 
the  same  degree.  Maculopajjular  syphilide  on  the  trunk  and 
extremities. 

Cured  after  twenty-five  inunctions. 


Tab.     9. 


i,„>,  i,„, ..  I  i)o.f.>,hoW,MurirhPti 


PLATE    10. 
ris  of  tbe  Tongue. 

Ft.  T^,  25  yeaxs  old,  vovkii^woman ;  admitted  Oct.  22, 
1896l  An  oloa-  of  unknown  orig^  a9>peared  on  the  tongue 
a  toobA.  ago. 

IHotwnt  Ooodition. — ^Tbe  i^t  mai^  oi  the  tongue  ex- 
hibits a  hazd  nodnle  aboat  as  laige  as  a  bean,  partly  embedded 
in  tbe  sobstanee  of  the  to^;ae  and  partly  lising  above  it«  level. 
In  the  center  is  a  ^at,  oral  idoer,  the  Boar  of  which  is  covered 
vith  a  gxareh-vhite  aecretaon.  Tbe  sobmaxillary  glands  on  the 
i^it  side  are  enlaiged  to  the  aae  of  a  paeon's  e^  and  painful 
on  pfeasore.  Oerdcal  and  axiQIaiy  glands  can  be  plainly  felt. 
G<i  nit  alii  nonnaL    A  fnr  acatteted  macnleB  on  the  tronk. 

ISav.  2,  Fapoles  ha^e  made  their  appeaiance  between  the 
macules.    Headache. 

Sobseqnent  Oooraew — ^After  twenty  inunctioos  complete 
regenetatioa  of  the  nodnle  on  the  tongue,  and  disa{^>earuice 
of  afl  olher  specific  symptoms. 

iVbr.  a.    Disefaaiged  omed. 


PLATE   11. 
Sclerosis  of  the  Right  Tonsil. 

W.  W.,  26  years  old,  roofer ;  admitted  June  29, 1896.  Patient 
says  he  has  always  been  healthy ;  since  May  13th  has  noticed 
a  swelling  of  the  right  tonsil  and  pain  on  swallowing. 

Present  Condition. — The  right  tonsil  is  larger  than  a 
pigeon's  egg  and  reaches  almost  to  the  middle  line,  forcing 
the  palatoglossal  and  palatopharyngeal  arches  far  apart.  It 
shows  considerable  intiltration  and  is  covered  with  partly 
necrosed  ulcei-s.  The  mucous  membrane  of  the  adjoining 
tissues  is  inflamed  and  slightly  swollen.  The  inflammation 
extends  as  far  as  the  uvula  on  the  left  side,  and  in  front  as  far 
as  the  anterior  border  of  the  soft  palate.  Under  the  angle 
of  the  jaw,  on  the  right  side,  is  a  slightly  movable  tvimor,  about 
as  large  jis  a  hen's  egg,  which  corresponds  to  the  submaxillary 
gland.  The  middle  cervical  glands  and  the  supraclavicular 
glands  on  the  right  side  are  as  large  as  beans  or  hazelnuts, 
easily  movable,  but  not  painful.  The  left  middle  cervical  and 
the  axillary  and  inguinal  glands  are  also  palpable,  but  not 
swollen. 

Jtdy  1.  A  roseolar  eruption  over  the  entire  trunk.  The 
necrotic  covering  of  the  sclerosis  has  fallen  off. 

July  5.  The  syphilide  and  the  glandular  swelling  increase. 
Granulation  is  forming  in  the  sclerosis. 

Treatment. — Gargles.  The  sclerosis  was  painted  with  tinct- 
ure of  iodin.     Twenty  inunctions. 


Tab.   U. 


PLATE   12. 
Indurative  Syphilitic  Bdema. 

J.  S.,  20  years  old,  butcher.  Under  treatment  from  Oct. 
24  to  Dec.  9,  1890. 

Two  months  ago  the  patient  contracted  a  sore  at  the  lower 
mai'gin  of  the  prepuce.  Within  a  week  the  entire  penis  was 
swollen  and  inflamed.  Three  weeks  ago  the  scrotum  began  to 
swell.  The  prepuce,  which  accordingly  has  been  swollen  for 
seven  weeks,  could  not  be  pushed  back  by  the  patient,  so  that 
he  can  give  no  account  of  the  subsequent  course  of  the  wound. 

Present  Condition. — Edematous  phimosis  of  the  prepuce. 
Lymphangitis  and  edema  of  the  skin  of  the  entire  penis. 
Indurative  edema  of  the  scrotum  with  superficial  erosions. 
Bilateral  inguinal  lymphadenitis.  General  disease  of  the  lym- 
phatic system.  Both  tonsils  are  enlarged  and  covered  with 
diphtheritic  papules.  Psoriasis  plantaris.  On  the  trunk  a 
papular  syphilide  in  process  of  regeneration.  Length  of  the 
penis,  13  cm.;  circumference  taken  about  the  center,  11.5 
cm. ;  circumference  of  the  scrotum,  measured  in  the  sagit- 
tal direction  from  the  root  of  the  penis  to  the  perineum,  26 
cm.;  circumference  of  the  scrotum,  measured  in  the  frontal 
direction  from  one  inguinal  fold  to  the  other,  30  cm.  The  skin 
of  the  scrotum  is  dark  red,  hot  and  infiltrated.  On  the  scrotum 
and  on  the  penis  the  skin  is  coming  off"  in  single,  attenuated 
layers;  a  few  erosions  on  the  scrotum.  The  integument  of  the 
scrotum  is  so  thick  and  infiltrated  that  the  testicles  cannot  well 
be  made  out  by  palpation. 

Treatment. — Irrigation  of  the  preputial  sac.  Compresses 
wet  in  alumimnn  acetate  solution.  On  Oct.  30th  inunctions 
were  begun,  and  the  swelling  and  infiltration  of  the  skin  of 
the  scrotum  and  penis  began  to  subside.  Reposition  of  the 
prepuce  revealed  a  shallow  scar,  as  large  as  a  pea,  on  the  inner 
surface  of  the  prepuce  and  on  the  lower  aspect  of  the  glans. 
Circumcision.  Entire  disappearance  of  all  the  symptoms  after 
thirty  inunctions. 


Tab.   12. 


PLATE    13. 

Recent  Macular  Eruption  (Roseola)  over  the  Entire  Surface 
of  the  Body. 

The  skin  of  the  entire  body  is  thickly  covered  with  red  spots, 
of  a  darker  color  on  the  dependent  portions  of  the  body  than 
about  the  trunk,  neck,  and  face ;  the  spots  are  not  shiny  and 
do  not  desquamate.  The  soles  of  the  feet  and  palms  of  the 
hands  exhibit  a  brownish,  papular  eruption  (psoriasis  plantaris 
et  palmaris). 

The  prepuce  is  indurated  and  shows  the  scar  of  a  sclerosis. 
The  inguinal,  cervical,  and  axillary  glands  are  enlarged. 

B.  L.,  23  years  old,  laborer;  admitted  Aug.  4,  1897.  The 
patient  states  that  he  was  discharged  from  a  hospital  a  month 
ago,  after  the  sore  on  his  penis  was  cured,  without  being  sub- 
jected to  any  general  treatment.  He  is  unable  to  give  the 
exact  date  of  his  infection  (a  little  more  than  two  months  ago). 

After  being  treated  with  inunctions  for  thirty  days  the  patient 
was  discharged  cured. 


Tab.  13. 


Lith,  Ansl  K Reichhold,  Munrhen . 


PLATES  14,   14a. 

Large    Macules    Mixed  with    Papules,  Scattered    over   the 
Entire  Body. 

H.  S.,  19  years  old;  admitted  Jan.  27,  1896.  The  history, 
as  given  by  the  patient,  is  extremely  inaccurate,  and  amounts 
to  this,  that  he  has  been  ill  three  months  and  has  done  nothing 
so  far  to  cure  himself. 

Present  Condition. — A  livid,  somewhat  infiltrated  scar,  the 
result  of  the  primary  lesion,  on  the  outer  layer  of  the  prepuce. 
Moist  papules  in  the  coronarj-  sulcus  of  the  penis  and  about  the 
anus.  An  abundant  macular  syphilide  scattered  over  the  trunk 
and  extremities.  Here  and  there  among  the  macules  are  seen 
large,  shiny  papules,  their  reddish-brown  color  contrasting  with 
the  livid  hue  of  the  macules.  The  soles  of  the  feet  exhibit 
dirty  yellow  papules  (psoriasis  plantaris).  Alopecia  and  slight 
desquamation  of  the  hairy  scalp.  On  the  forehead  a  maculo- 
papular  syphilide.  Both  tonsils  are  enlarged  and  covered  with 
coalescent,  suppurating  ulcers  (papules). 

Treatment. — Labarraque's  solution  externally.    Inunctions. 

Black  Plate  (PI.  14a) :  Dorsal  view,  showing  the  widespread 
large  macular  syphilide.  Colored  Plate :  Right  forearm,  with  the 
same  large  macular  syphilide. 


Tab.  14  a. 


PLATE   15. 
Erythema  Figuratum. 

H.  J.,  42  years  old,  saloon-keeper;  admitted  July  12,  1896. 
Became  infected  eighteen  months  ago,  at  which  time  he  was 
subjected  to  inunctions  at  this  hospital.  Since  then  he  has  had 
several  relapses,  taking  the  form  of  papules  on  the  mucous 
membranes,  which  were  treated  with  milder  remedies  (internal 
administration  of  mercurial  preparations,  potassium  iodid,  and 
external  applications  of  chromic  acid).  He  says  the  eruption 
appeared  a  week  ago.  The  patient  is  a  moderate  drinker  and 
smoker. 

Present  Condition. — On  the  dorsum  of  the  penis  is  an  infil- 
trated scar  as  large  a.s  a  penny.  The  lymph-glands  which  can 
be  felt  ai-e  spindle-shaped.  About  the  middle  of  the  right 
border  of  the  tongue  is  a  papular  efflorescence  about  as  large  as 
a  pea,  with  ulcerated  surface.  Otherwise  the  mucous  mem- 
branes are  free  from  disea.se.  The  skin  of  the  trunk  and  of  the 
upper  extremities  is  covered  with  a  pale-red  exanthema,  arranged 
in  sinuous  figures  formed  by  the  confluence  of  circular  erup- 
tions. The  rash  is  distributed  over  the  extensor  surfaces  of  the 
arms  and  over  the  trunk,  being  more  di.stinct  on  the  sides  of 
the  thorax  than  on  the  back  and  buttocks.  The  graceful  figures 
stand  out  very  plainly  after  the  naked  body  has  been  exposed 
to  the  air.  The  patient  complains  of  headache,  worse  at  night. 
Psychical  condition  intact.  Pupillary  reaction  and  tendon- 
reflexes  normal. 

Treatment.— Potassium  iodid     |  -  -  -i  a/w   .      a 
Potassium  bromid  )  "      ^  •  '    )• 

To  be  taken  at  night. 

Cured. 


Tab.  15. 


gr^. 


nvuiuunit .  Muiiawti 


PLATE  16. 
Erythema  Figuratum. 

( Ery theme  circinee —  Foil  rnier. ) 

E.  B.,  26  years  old,  clerk;  admitted  Dec.  21,  1896.  The 
specific  infection  occurred  in  Februar}'  of  the  present  year; 
the  patient  was  treated  with  injections  at  the  time.  For  the 
past  two  weeks  he  has  had  difficulty  in  swallowing ;  he  has  no 
knowledge  of  any  rash. 

Present  Condition. — Ei-oded  papules  on  both  tonsils.  The 
latter,  a.s  well  as  the  pillars  of  the  fauces  and  the  posterior  wall 
of  the  pharynx,  are  swollen  and  inflamed.  The  entire  lym- 
phatic system  is  diseased.  A  pale-red  eruption  appears  dis- 
tributed almost  symmetrically  over  the  skin  of  the  trunk  and 
extremities.  The  individual  patches  of  the  eruption  are  circu- 
lar in  shape  and  vary  in  size  from  a  penny  to  a  dollar.  By  the 
confluence  of  adjoining  patches  the  eruption  assumes  the  form 
of  festoons  or  garlands,  the  general  arrangement  of  the  figures 
corresponding  to  the  slant  of  the  ribs  on  the  back,  chest,  and 
sides  of  the  thorax.  The  face,  palms  of  the  hands,  and  soles  of 
the  feet  are  free. 

Cured  after  twenty-five  inunctions. 


Tab.  16. 


Lifh.Arusi.  tl Reichhold.  Mundien. 


PLATE   17. 
Syphilitic  Papules  Distributed  over  tfie  Entire  Body. 

L.  M.,  30  years  old,  laborer;  admitted  July  4,  1897.  The 
patient  says  he  performed  his  last  coitus  two  months  ago. 
Immediately  afterward  he  noticed  a  sore  on  the  foreskin.  The 
eruption  he  noticed  eight  to  ten  days  ago.  Has  had  no  treat- 
ment so  far. 

Present  Condition. — The  skin  of  the  entire  body  is  of  a 
brownish  hue'and  covered  with  copper-colored  nodules  as  large 
as  lentils.  The  eruption  is  situated  mostly  at  the  sides  of  the 
thorax,  on  the  abdomen,  and  on  the  flexor  surfaces  of  the  ex- 
tremities. Most  of  these  papules  already  show  a  whitish  dis- 
coloration of  the  epidermis  at  the  apex,  which  can  be  removed 
in  some  of  them  by  very  light  abrasion  with  the  finger-nail. 
All  the  lymphatic  glands  are  moderately  enlarged.  On  the 
dorsal  aspect  of  the  neck  of  the  penis  is  a  livid,  recently  healed, 
sclerosis,  surrounded  by  a  good  deal  of  induration  and  infiltra- 
tion. The  mucous  membranes,  palms  of  the  hands,  and  soles 
of  the  feet  are  not  involved.  A  few  papules  are  seen  on  the 
face,  at  the  roots  of  the  hair.  The  hairy  scalp  shows  slight 
seborrhea,  but  no  distinct  i:)apules. 

Treatment. — Antiseptic  mouth-wash;  baths;  twenty-five 
inunctions.    Cured. 


Tab.  17. 


1 


/ 


LitA-Ansl  F  Reuhlwld.  Miinchen. 


PLATE  18. 
Papulopustular  Syphilide.    Jaundice. 

M.  S.,  24  years  old,  nurse.  Under  treatment  from  Feb.  11  to 
March  20,  1897.  The  patient  says  she  had  jaundice  five  weeks 
before  entering  the  hospital ;  the  eruption  appeared  only  dui'- 
ing  the  last  week.  She  has  suffered  a  good  deal  lately  with 
frontal  headache,  especially  at  night;  also  complains  of  sore 
throat.     Last  coitus  three  months  ago. 

Present  Condition. — On  the  right  labium  majus  a  sclerosis 
as  large  as  a  hazelnut,  with  ulcerated  surface.  General  gland- 
ular enlargement.  The  skin  and  mucous  membranes,  where- 
ever  visible,  present  an  intense  yellow  discoloration  and  are 
thickly  covered  with  innumerable  papules,  varying  in  size  from 
a  millet-seed  to  a  lentil.  Here  and  there,  especially  on  the 
back  and  in  the  intermammillary  region,  are  numerous  pus- 
tules covered  with  hemorrhagic  crusts.  Recent  eruption  of 
psoriasis  plantaris.  Mucous  membrane  of  the  mouth  intact. 
The  face  wears  an  expression  of  suffering.     Violent  headache. 

Treatment.  —  Labarraque's  solution  locally.  Antiseptic 
mouth-wash. 

Feh.  15.  Patient  very  much  prostrated  ;  complains  of  violent 
headache,  especially  at  night;  temperature  normal;  percussion 
and  palpation  bring  out  no  enlargement  of  liver  or  spleen. 
Inunctions. 

After  fifteen  inunctions  the  jaundice  disappeared  entirely,  the 
patient  began  to  feel  better,  and  the  specific  symptoms  began  to 
subside,  the  papules  and  pustules  being  replaced  by  pigmenta- 
tion. After  thirty  inunctions  the  patient  was  discharged  cured 
on  March  20th. 


Tab.   18. 


>IA  -^ 


m 


<*.- 


v» 


PLATE   19. 

Small,  Aggregated  Papules  (Lichenoid  Syphilide,  Relapsing 

Form). 

S.  A.,  19  years  old,  seamstress ;  admitted  Jan.  24, 1896.  Patient 
was  treated  for  sjphilis  in  Sept.  and  Oct.,  1895.  The  present 
trouble  developed  a  month  ago. 

Present  Condition. — On  both  labia  majora  and  in  the 
genitocrural  fold  on  both  sides  are  seen  papules  as  large  as 
peas  and  elevated  above  the  surrounding  level.  Over  the 
sacrum  and  on  the  nates,  small  aggregated  papules.  Some  of 
the  papules  are  desquamating,  others  show  a  reddish-brown 
pigmentation.  Similai-  patches  are  seen  over  the  knee-joint, 
on  the  lower  abdomen,  and  at  the  back  of  the  neck.  Moderate 
itching  in  the  affected  parts. 

Cured  after  twenty  inunctions  of  5  g.  (3jss)  each. 


Tal>    1 ;». 


*0 


«# 


9» 


»^ 


^v^: 


<» 


:•.«> 


GO 


FteichhoUL,  Miinchen . 


PLATE   20. 

Papulosquamous  5yphilide. 

T.  J.,  34  years  old,  hostler ;  admitted  March  27, 1896.  Toward 
the  end  of  June,  1895,  four  weeks  after  coitus,  the  patient  had 
an  ulcer  on  the  penis.  He  then  had  a  private  physician,  and 
was  treated  with  yellow-precipitate  ointment  and  sublimate 
baths  locally.  After  the  ulcer  healed  the  patient  again  indulged 
in  sexual  intercourse ;  three  weeks  later  an  eruption  appeared 
over  the  entire  body  (from  his  description  a  macular  and  papu- 
lar syphilide).  On  Aug.  20,  1895,  he  applied  for  admission  to 
the  general  hospital,  and  was  treated  until  Oct.  31st.  He  was 
subjected  first  to  twenty-three  inunctions  with  calomel,  and 
then  to  forty -seven  inunctions  with  gray  ointment.  On  Nov. 
24th  patient  applied  for  admission  to  the  Rudolfspital.  He 
then  complained  of  pains  in  the  head,  in  the  epigastrium,  and 
in  the  thorax.  The  patient  was  jjale ;  the  skin  of  the  trunk 
was  thickly  covered  with  livid  and  brownish  patches  as  large 
as  a  pea,  the  remains  of  an  old  syphilide ;  the  epidermis  over 
most  of  the  patches  is  marked  by  fine  furrows.  Inguinal,  axil- 
lary, and  cervical  glands  enlarged.  Incipient  leucodermia 
colli.  Pharyngitis.  The  internal  organs  were  normal.  On 
Dec.  11th  a  tassel-shaped  eruption  appeared  on  the  forehead. 
On  Dec.  18th  the  tassel  disappeared,  leaving  a  livid  spot,  and 
appeared  in  another  place.  At  the  same  time  several  papules 
appeared,  disposed  in  a  circle  about  the  left  nostril,  and  also 
another  papular  eruption  on  the  throat.  The  gums  are  eroded. 
Gingivitis.  Seborrhoea  capitis.  Alopecia.  General  neuras- 
thenia. On  Dec.  24th  single  pustules  appeared  on  the  head. 
On  Jan.  2d  the  patient  felt  completely  cured,  and  was,  at  his 
own  request,  discharged  from  the  hospital.  On  March  27, 1896, 
he  again  asked  to  be  admitted  to  the  hospital.  Examination 
revealed  the  following  condition  :  in  addition  to  the  remains  of 
the  old  syphilide,  which  existed  during  his  former  stay  at  the 
hospital,  the  entire  body  is  now  covered  with  a  new  eruption ; 
the  center  of  the  papules,  which  vary  in  size  from  a  pea  to  a 
bean,  consists  of  a  raised,  whitish  scab,  while  the  margin  is  of  a 
light-red  color.  In  some  places  the  central  scab  has  fallen  off, 
leaving  only  a  livid,  red  patch,  slightly  raised  above  the  level  of 


m 


.%, 


Tab.  20. 


^ 


LdJi.  A/isI  A'  ReiclilwLd,  Miinchf/i . 


the  skin.  The  center  of  these  patches  is  badly  degenerated  and 
converted  into  a  hemorrhagic  wound,  and  around  it  are  grouped 
thick  clusters  of  small,  miliary  papules.  The  isolated,  small 
nodules  show  a  slight  whitish  discoloration  at  the  apex,  but  no 
desquamation.  In  addition,  the  remains  of  the  old  syphilide 
are  seen  here  and  there  (at  the  top  of  the  illustration,  for  in- 
stance) in  the  form  of  light,  reddish-yellow  patches  of  epidermis 
marked  by  delicate  striations.  The  lower  part  of  the  navel  is 
occupied  by  a  phagedenic,  moist  papule.  The  general  color  of 
the  skin  is  dirty  yellow,  with  here  and  there  irregular  lighter 
areas,  the  remains  of  foi'mer  eruptions.  Ulcerating  papules  on 
the  scrotum  ;  papules  on  the  mucous  membrane  of  the  mouth 
and  of  the  lower  lip,  and  on  both  tonsils. 
Treatment. — Mixed.    Cure. 


PLATE   21. 
Papular,  Orbicular  Syphilide. 

M.  E.,  servant-girl,  26  years  old;  admitted  Oct.  1,  1895.  The 
patient  became  aware  of  her  syphilitic  disease  by  accident,  a 
police-surgeon  calling  her  attention  to  it  on  the  occasion  of  her 
being  incarcerated,  although  she  knew  that  an  eruption  had 
•begun  to  develop  in  the  genital  region  for  a  year,  and  on  the 
lower  limbs  and  on  the  neck  for  the  last  five  months.  She, 
however,  attached  no  importance  to  it  and  did  nothing  for  it. 
She  has  never  given  birth,  menstruates  regularly,  and  says  that 
she  had  her  last  coitus  more  than  a  year  ago. 

Present  Condition.  —  In  both  genitocrural  folds,  at  the 
edges  of  both  labia  majora,  and  about  the  anus  are  seen  prolif- 
erating papules,  some  of  which  have  run  together.  Part  of  the 
trunk  is  covered  with  the  i)igmented  remains  of  a  papulo- 
serpiginous  syphilide,  the  rest  by  an  irregular  (figurate)  syphi- 
lide made  up  of  large  macules.  On  the  legs  is  a  lichenoid, 
brownish-yellow  syi)hilide,  arranged  in  groups.  On  the  inner 
aspect  of  each  thigh  is  an  elliptical,  orbicular  syphilide.  The 
margin  is  composed  of  .small,  lichenoid  papules  surrounded  by 
a  coppery  halo;  the  center  is  brown,  with  a  shade  of  gray,  and 
the  epidermis  is  in  part  undergoing  desquamation.  Above, 
the  line  of  small  papules  is  irregular,  so  that  the  margin  of  the 
entire  ellipsoid  figure  appears  broken.  In  addition,  all  the 
lymph-glands  are  swollen ;  the  mucous  membranes  are  free. 

After  local  treatment  with  sublimate  and  gray  plaster,  and 
forty  inunctions,  the  syphilide  disappeared,  leaving  some  pig- 
mentation.' The  patient  was  discharged  cured  after  having 
been  under  treatment  sixty-five  days. 


CM 


.•^<i^ 


PLATES    22,   23. 

Irregularly  Distributed  Papular  Syphilide. 

A.  M.,  36  years  old;  admitted  June  '2o,  1890.  Four  mouths 
ago  the  patient  first  noticed  an  eruption  of  small  nodules  on 
her  arms.  These  nodules  degenerated  and  formed  shallow 
ulcers,  Which  dried  up  six  weeks  ago.  The  group  on  the 
left  side  of  the  neck,  at  the  hair-line,  and  the  patches  in  the 
left  eyebrow  developed  six  months  ago. 

Present  Condition. — The  inner  portion  of  the  right  eyebrow 
(PL  22)  presents  a  group  of  hard,  shiny  papules  ranging  in  size 
from  a  lentil  to  a  pea ;  between  the  two  larger  ones  is  a  tough 
scar  surrounded  by  infiltration. 

At  the  edge  of  the  hair,  in  the  neck,  is  a  group  of  copper- 
colored  papules,  closely  crowded  together  for  the  most  part, 
resting  on  an  infiltrated  base.  The  center  is  occupied  by 
desquamating  scars  continuous  with  the  bands  of  infiltrated 
tissue,  which  are  partly  covered  with  scabs  and  appear  ar- 
ranged in  folds;  distinct,  isolated  nodules,  somewhat  larger 
than  lentils,  are  disposed  about  the  jicripher}-.  Below  this 
is  another  group,  the  center  of  which  consists  of  a  purulent 
infiltrate,  with  infiltrated,  desquamating  edges,  surrounded  by 
fresh,  pale  nodules.  A  third  patch  presents  a  keloid  appear- 
ance;, the  infiltration,  which  is  similar  to  that  in  the  center  of 
the  papules,  being  depressed  in  the  center  and  at  the  edges. 
Other  similar  patches  are  found  on  the  extremities. 

In  the  gluteal  folds  and  in  the  prolongation  of  the  right 
labium  majus  is  a  group  of  nodules  as  large  as  the  head  of  a 
pin,  some  of  which  are  not  eroded.  Other  papular  eruptions, 
similar  to  those  shown  in  the  illustration,  are  scattered  more 
or  less  profusely  over  the  entire  body ;  some  of  these  show  the 
crater-like  central  scar,  others  merely  pale  nodules,  varying  in 
size  from  the  head  of  a  pin  to  a  lentil  or  a  pea,  resting  directly 
on  the  skin. 

Wherever  the  infiltrated  areas  have  coalesced,  the  entire  skin 
is  converted  into  a  plaque  of  infiltrated  tissue.  The  crater-like 
scars  are  tough,  with  everted,  glistening  edges,  and  resemble 
keloids.  The  lymphatic  glands,  although  not  swollen,  are  hard 
to  the  touch.  The  patient  is  pale,  but  not  anemic.  She  has 
been  pregnant  seven  times ;  one  child  born  at  term  and  six 
abortions  in  the  third  or  fourth  month ;  she  has  menstruated 
regularly  for  the  last  four  years.  The  patient  has  always  been 
well,  comes  of  a  healthy  family,  and  has  no  knowledge  of  her 
disease. 


Tab.  23. 


■'J! 


f0" 


'^„ 


lUfuAnst  F.  Reicbhold.  Mimchert 


PLATES    24,  24a. 
Leukoplasia  of  the  Neck.    Papules  on  the  Genitalia. 

A.  B.,  18  years  old,  servant-girl.  Has  never  had  a  venereal 
disease.  In  the  beginning  of  Dec,  1895,  she  began  to  be 
troubled  with  burning  during  micturition ;  at  the  same  time 
several ''  pustules  "  developed  on  the  outside  of  the  labia  majora, 
which  burst  after  several  days  and  healed  over.  There  was  also 
a  painful  swelling  of  the  right  inguinal  glands,  lasting  several 
weeks  and  disappearing  finally  wdth  rest  in  bed  and  compresses. 
In  Feb.,  1896,  she  was  troubled  with  pain  in  the  throat,  and 
for  two  weeks  was  unable  to  swallow  solid  food.  These  symp- 
toms improved  after  gargling  with  alum.  A  few  days  afterward 
an  erythematous  eruption  appeared  on  the  throat,  on  the  flexor 
surface  of  both  elbows,  and  on  both  legs.  Since  the  end  of 
March  the  eruption  has  been  brown.  On  May  23d  she  caine 
under  hospital  treatment ;  up  to  that  time  she  had  not  con- 
sulted a  physician.  Last  coitus  six  months  ago  ;  last  menstru- 
ation, April  29th.     Has  never  given  birth,  nor  had  an  abortion. 

Present  Condition. — Eroded,  edematous  papules  on  both 
large  and  small  labia,  especially  on  the  right  side;  inguinal 
glands  on  both  sides  much  enlarged ;  at  the  anus  the  mark  of 
an  old  papule.  On  the  lower  extremities  a  specific  eruption  in 
process  of  regeneration  ;  intense  leukoplasia  of  the  neck ;  both 
tonsils  enlarged  and  ulcerated. 

Cured  after  twenty  inunctions. 

Black  Plate  (PL  24a) :  Front  view  of  the  same  case. 


Tab.  24. 


Reuhhold.  Miinchen . 


Tab,  24  a, 


PLATE   25. 
Flat,  Glistening  Papules  on  the  Forehead  and  Face. 

N.  M.,  26  years  old,  locomotive  engineer;  admitted  Oct.  5, 
1896.  The  forehead  jjresents  irregular  jiatehes  of  red  and  a  few 
papules  but  slightly  raised  above  the  level  of  the  skin.  There 
is  a  narrow  circle  of  red  at  the  perii)hery  of  the  papule ;  the 
center  shows  a  brown  discoloration,  while  the  epidermis  in  the 
intermediate  zone  has  a  tense  and  faintly  glistening  appearance. 
On  the  ahe  of  the  nose  and  on  the  chin  are  similar  papules,  less 
distinctly  marked. 

Other  symptoms :  a  maculopapular  syphilide  on  the  trunk ; 
moist  papules  on  the  skin  of  the  scrotum  and  on  the  skin  of 
the  penis ;  on  the  foreskin  the  scar  of  a  sclerosis. 


^ 


PLATE  26, 
Syphilitic  Alopecia  Areolaris. 

S.  H.,  25  years  old,  works  in  a  brush-factory  ;  admitted  April 
13, 1896.  In  Nov.,  1895,  patient  had  a  chancre  ;  in  December  he 
was  treated  in  the  hospital  for  an  eruption.  The  present  symp- 
toms developed  three  weeks  ago. 

Present  Condition.— On  the  f(  rehead  and  on  the  hairy 
scalp  are  numerous  pustules,  some  with  the  scabs  still  on 
them.  Where  a  pustule  has  dried  up  and  shed  its  scab  the 
hair  is  gone  completely,  the  base  of  the  pustule  is  converted 
into  a  glistening  scar,  and  the  hair-follicle  is  not  visible.  The 
general  growth  of  hair  is  good,  but  there  are  areas  where  the 
hair  is  loose,  especially  about  the  "bald  spot."  The  rest  of 
the  body  presents,  in  addition,  a  large  macular  syphilide  on 
the  trunk  and  eroded  papules  about  the  anus  and  genitalia. 
The  lymph-glands  in  general  are  swollen.  Additional  erup- 
tions of  a  papulopustular  character  appeared  later  on  the 
hairy  scalp,  so  that  this  part  of  the  body  is  to  be  regarded  as 
the  principal  seat  of  the  syphilitic  eruption. 

Cured  by  the  use  of  white-precipitate  ointment  on  the  head 
and  twenty  inunctions  of  5  g.  (3jss)  each. 


PLATE    26a. 
Papules  on  the  Hairy  Scalp. 

T.  A.,  33  years  old,  works  in  a  market.  Under  treatment 
from  May  26  to  June  25,  1897.  Patient  has  never  had  a 
venereal  disease.  He  began  to  notice  his  present  condition 
two  weeks  ago.     Last  coitus  four  weeks  ago. 

Present  Condition. — Ulcerated  papules  on  the  lower  surface 
of  the  penis  and  on  the  scrotum.  BTultiple  swelling  of  the 
inguinal  glands.  Raised  papules  about  the  anus.  Maculo- 
papular  syphilide  on  the  trunk  and  extremities.  Papulopus- 
tular eruption  on  the  head,  with  alopecia  areolaris.  Cervical 
and  axillary  glands  enlarged.  Palmar  and  plantar  psoriasis. 
The  mvicous  membranes  of  the  mouth  and  throat  are  not 
affected. 

Treatment. — White-precipitate  ointment.  Labarraque's  so- 
lution locally.  Antiseptic  mouth-wash.  Cured  after  twenty- 
five  inunctions. 


Tab.  26  a. 


j^ 


PLATE   27. 
Small  Pustules  on  the  Face. 

E.  H.,  28  years  old,  hostler ;  admitted  Feb.  15, 1896.  Five  weeks 
ago  an  ulcer  formed  on  the  frenum.  During  the  past  week 
swelling  and  suppuration  of  the  inguinal  glands  on  the  right 
side.  Meanwhile  a  typifal  induration  developed  in  the  base  of 
the  ulcer,  and  on  the  trunk  a  scanty  papular  sypliilide.  When 
the  inunctions  were  begun  the  eruption  became  more  distinct 
and  spread  to  the  back,  neck,  and  face.  On  the  face  the  erup- 
tion takes  the  form  of  hard  nodules,  ranging  in  size  from  the 
head  of  a  pin  to  a  pea,  and  surrounded  by  a  reddish-brown  or 
copper-colored  halo.  The  center  of  the  pustule  consists  of  a 
horny  core,  which  can  be  easily  removed,  exposing  the  newly 
formed,  glistening  epidermis  beneath.  8ome  of  the  nodule« 
are  collected  in  groups. 

Cured  after  twenty-five  inunctions. 


/** 


Tab.  21. 


•  m 


i    , 


0 


J/ 


Tab.  2Sa. 


PLATES    28,   28a,   28b. 
Pustular  Syphilide. 

P.  J.,  38  years  old  ;  ;uln)ittc<l  Dec.  1,  ISl),').  I'ationt  is  sick  forthe 
first  time ;  liad  liisiast  coitus  two  months  ajjo,  ami  first  noticed 
the  eruption  three  weeks  ago.  He  often  suffered  fi-om  sore 
throat  when  he  was  a   child. 

Present  Condition. — Both  tonsils  are  enlarged  and  fissured. 
The  left  presents  a  ragged  ulcer  with  shreds  of  necrotic  tissue 
clinging  to  the  surface.  The  suhniaxillary  glands  are  a*  large 
as  pigeons'  eggs,  the  middle  cervical  glantls  ahout  the  size  of 
hazelnuts.  The  axillary  glands  are  also  eidarged,  hut  the  epi- 
trochlear  and  inguinal  glands  are  practically  normal  in  size. 
The  trunk  is  covered  with  an  extensive  macular  syphilide.  In 
the  epigastrium  are  small,  lichenoid  papules  which  already  show 
a  yellow  discoloration.  Numerous  papules  and  pustules,  some 
of  which  are  shedding  their  scabs,  are  distributed  over  the  ex- 
tensor surfaces  of  the  upper  extremities,  and  here  and  there  on 
the  thorax  and  hack.  The  pustules  are  more  numerous  on  the 
back,  especially  in  the  sacral  region,  and  on  the  legs,  where  they 
are  larger  and  run  together  to  form  eczematous  pustules  cov- 
ered with  scabs,  especially  al)out  the  ankles.  On  the  upper  ex- 
tremities the  pustules  are  of  a  light  coppery  hue  at  the  periph- 
ery ;  those  on  the  legs,  on  the  other  hand,  are  livid  and  of  a  dark 
coppery  red. 

The  hairy  scalp  and  the  palms  of  the  hands  are  also  the  seat 
of  a  papular  eruption.  The  acneiform  pustules  on  the  legs  are 
surrounded  by  extensive  infiammatory  areas  which  form  an 
almost  continuous  sheet.  \Vliere  the  process  has  been  going  on 
for  some  tim'e  the  epidermis  is  covered  with  broad,  flat  crusts, 
and  comes  off  in  large  sheets  wherever  the  pustules  are  closely 
crowded  together :  at  first  it  becomes  puckered  over  the  in- 
Hanied  area,  then  cracks,  and  finally  loosens  and  comes  oH". 
The  new  epidermis  underneath  is  also  inflamed. 

Patient  was  treated  with  hypodermatic  injections  of  subli- 
mate, and  discharged  after  five  weeks,  cured. 

Colored  Plate :  Part  of  the  eczema-pustules  on  the  left  leg,  seen 
in  the  black  plate  (Plates  28a,  28b). 


Tab.  :^S. 


0^ 


I' 


t 

.#. 

-_ 

■^ 

.* 

'4$ 

L 

Lah..Anst  t:  RjfidOiold.  Munrhen 

Tab.  28  b. 


PLATES  29,   29a. 

Proliferating  Pustular  Ulcers  (Frambesia  or  Yaws)  on 
Both  Calves. 

K.  E.,  18  years  old;  admitted  Feb.  21,  1896.  Patient  was 
under  treatment  in  this  hospital  last  year  for  gonorrhea  of  the 
urethra,  vagina,  and  canal  of  the  cervix.  A  short  time  after 
she  was  discharged  from  the  hospital  she  contracted  a  sclerosis 
on  the  left  labium  minus ;  was  treated  for  six  weeks  and  dis- 
charged after  all  specific  symptoms,  except  general  glandular 
enlargement,  had  disappeared.  Until  a  week  ago,  the  patient 
says,  she  was  quite  well.  On  that  day  she  felt  a  violent  itching 
on  both  legs ;  scratching  was  followed  by  the  appearance  of 
pustules,  which  were  later  converted  into  ulcers. 

Present  Condition  — On  the  right  leg,  below  the  calf,  is  a 
node  as  lai-ge  as  a  dollar,  composed  of  several  smaller  ones:  the 
center  is  occupied  by  a  discolored  wound  covered  with  a  crust, 
while  the  periphery  is  made  up  of  seven  separate  nodules  as  large 
as  a  bean,  rising  from  2  to  3  mm.  above  the  level  of  the  skin. 
The  surface  of  each  nodule  is  furrowed  and,  in  places,  destitute 
of  epidermis  so  as  to  present  fissures,  while  the  remaining 
parts  are  covered  with  slightly  adherent  crusts  of  dried  epider- 
mis. The  periphery  of  the  entire  node  is  slightly  inflamed, 
and,  like  all  parts  of  the  node  itself,  painful  on  pressure. 
Above  the  large  node  is  a  fresh  pustule.  A  similar  sore,  only 
much  greater  in  extent,  is  found  on  the  left  leg  (see  PI.  29a). 
There  is  typical  swelling  of  the  inguinal  glands,  but  they  are 
not  painful.  The  axillary  and  cervical  glands  are  also  enlarged. 
The  genitalia  are  flabby.  Gonorrhea  of  the  urethra  and  vagina. 
The  patient  says  that  the  ulcers  on  the  legs  are  painful,  espe- 
cially at  night. 

Treatment. — Inunctions.  Compresses  of  aluminum  acetate 
solution. 


i 


Tab    29. 


/ 


LUh.  Anst  E  ReJchhjold.  Miinchen 


Tab.  29  a. 


PLATE   30. 
Psoriasis  Syphilitica  Plantaris. 

R.  R.,  24  years  old,  cashier ;  admitted  June  18,  1896.  First 
attack.  The  eruption  appeared  five  days  ago.  No  history  of 
a  previous  disease  or  its  duration  could  be  obtained. 

Present  Condition. — Numerous  papules,  varying  in  size 
from  the  head  of  a  i)in  to  a  pea,  are  developing  on  the  soles, 
especially  in  the  ht)llow  of  the  foot.  Their  peculiar  reddish- 
brown  discoloration  and  hard  consi.stency  indicate  a  horny 
change  of  the  thick  plantar  epidermis.  Numerous  follicular 
papules  are  seen  on  both  labia  majora,  at  the  commissure,  and 
about  the  anus.  General  glandular  enlargement.  Pale,  papu- 
lar syphilide  on  the  trunk. 

Treatment.  —  Labarraque's  solution  locally.  Antiseptic 
mouth-wash.     Iiunictions  of  5  g.  (Sjss)  ung.  hydrarg. 

Course. — After  twenty  inunctions  all  syphilitic  symptoms 
disappeared.     Patient  was  discharged  July  11th,  cured. 


Tab.  30. 


\ 


\ 


m 


•     • 


#   ' 


PLATE   31a. 
Eroded  Papules  between  the  Toes. 

T.  J.,  20  years  old,  seivant-girl ;  admitted  Nov.  25,  1896. 
The  patient  says  this  is  the  first  time  she  is  sick,  and  that  she 
noticed  the  disease  in  the  genitaUa  for  the  fii-st  time  five  weeks 
ago. 

Present  Condition. — Fhat,  macerated,  coalescing  papules  on 
the  inner  surfaces  of  the  third,  fourth,  and  fifth  toes.  The  toes 
themselves  are  swollen  and  inflamed.  On  the  soles  of  both 
feet,  papules  covered  with  hoiny  epidermis  (psoriasis).  At  the 
edges  of  the  labia  majora  and  about  the  anus  raised  papules, 
some  of  which  have  run  together.  Figurate,  macular  syphilide 
on  the  trunk.  Inguinal  and  cervical  glands  enlarged.  Both 
ton.sils  are  swollen  and,  together  with  the  surrounding  palato- 
glossal arches,  inflamed  and  covered  with  eroded  papules. 

Treatment. — Sublimate  baths  for  the  feet.  Applications  of 
5  per  cent,  white-precipitate  ointment.  Baths.  Antiseptic 
mouth-wash.     Inunctions.     Cured  in  thirty  days. 


PLATE   31b. 
Papules  and  Fissures  between  the  Toes. 

P.  B.,  27  years  old,  charwoman,  married;  admitted  Nov.  19, 
1895.  The  patient  says  she  first  noticed  her  present  disease 
three  months  ago.  At  that  time  she  became  aware  of  a  moist 
spot  between  the  fourth  and  fifth  toes,  which  she  took  for  a 
corn.  The  other  ulcers  developed  gradually;  there  was  a  good 
deal  of  tissue-destruction,  and  for  the  pa.st  month  walking  has 
been  attended  with  great  pain.  The  inflammation  surrounding 
the  ulcers  has  been  increasing  during  the  past  three  weeks ; 
the  ulcers  themselves  have  become  deeper. 

Present  Condition.  —  Degenerating  papules  between  the 
first  and  second  toes,  presenting  much  suppuration  and  necro- 
sis, with  a  hemorrhagic  scab  in  the  center.  Between  the  fourth 
and  fifth  toes,  which  are  also  swollen,  similar  degenerating 
papules  are  seen.  All  the  anterior  portion  of  the  foot  is  swollen 
and  inflamed.  The  labia  majora  are  edematous  and  covered 
with  coalescing  papules ;  on  the  labia  minora  and  about  the 
anus  are  isolated  eroded  papules. 

Treatment.  —  Labarraque's  solution  (toes  and  genitals). 
Baths.  White-precipitate  ointment  (toes).  Inunctions.  Cured 
in  twenty-seven  days. 


d 


-•  F.  Hpirhhiihl  Miuidi< 


PLATE  32. 
Syphilitic  Paronychia  of  Both  Hands. 

B.  J.,  50  years  old,  laborer ;  admitted  Oct.  o,  1896.  The  patient 
ha.s  been  suffering  from  syphili.'*  for  the  past  twenty-one  months, 
and  was  treated  in  the  hospital  a  year  ago.  His  present  attack 
began  a  month  ago. 

Present  Condition. — The  disease  has  attacked  the  follow- 
ing parts  with  varying  intensity :  thumb,  index  and  middle 
fingers  of  the  right  hand ;  index,  middle,  and  ring  fingers  of 
the  left  hand ;  big  toe  of  the  left  foot.  Wliere  the  disease  is 
mild  the  fingers  show  merely  a  swelling  and  redness  of  the 
distal  phalanges  and  slight  ulceration  at  the  nnirgin  of  the  nail. 
Those  which  are  more  severely  attacked,  as  the  index  of  the 
right  and  the  middle  and  ring  fingers  of  the  left  hand,  are  very 
red,  and  the  distal  phalanx,  especially  the  margin  of  the  nail, 
swollen  to  the  finger-tip ;  the  nails  are  turned  in  and  separated 
from  their  matrix.  The  latter  is  converted,  at  the  margin  and 
under  the  nail,  into  a  granulating,  suppurative  ulcer.  Papules 
on  the  buccal  mucous  membrane,  about  the  anus,  on  the 
scrotum,  and  on  both  forearms.  The  patient  complains  of  con- 
stant burning-pains  in  the  tips  of  his  fingers,  which  he  carefully 
guards  against  injury. 

Treatment. — Sublimate  baths  for  the  hands.  Inunctions. 
Cured  after  twenty-five  inunctions.  The  nails  are  discolored  a 
brownish-black,  brittle,  and  turned  in  at  the  edges. 


I 


CM 


^X; 


) 


'A 


mk 


y 


PLATE  33. 
Proliferating,  Eroded  Papules  of  Diphtheritic  Character. 

J.  M.,  27  years  old,  coachman;  admitted  June  12,  1897. 
Patient  has  never  had  a  venereal  disease.  Noticed  his  present 
trouble  four  weeks  ago.     Last  coitus  three  months  ago. 

Present  Condition. — Diphtheritic  papules  on  the  glans 
penis,  at  the  edge  and  on  the  inner  surface  of  the  prepuce,  on 
the  skin  of  the  penis,  and  on  the  scrotum.  Proliferating 
pajniles  on  the  perineum,  on  both  thighs,  and  on  the  buttocks. 
Desquamating  papules  on  the  palms  of  both  hands  and  the 
soles  of  both  feet.  Raised  papules,  of  a  livid  color,  covered 
with  crusts,  on  the  skin  of  the  abdomen.  Inguinal,  axillary, 
and  epitrochlear  glands  swollen. 

Cured  after  ten  inunctions  and  ten  injections  of  1  per  cent, 
sublimate  solution. 


CO 


*i- 


■'^ 


PLATE  34. 
Proliferating  Papules. 

T.  A.,  17  years  old,  servant-girl ;  admitted  July  2, 1897.  First 
venereal  attack.  Patient  first  noticed  the  condition  of  the 
genitals  two  weeks  ago.     Last  coitus  three  weeks  ago. 

Present  Condition. — At  the  edges  of  the  labia  majora,  on 
the  perineum,  and  about  the  anus  proliferating,  raised  papules, 
some  of  which  present  necrotic  decay  and  suppuration  in  the 
center. 

Inguinal  glands  swollen  and  hard  on  both  sides.  The  os 
displaced  to  the  left,  intact. 

Cured  after  twenty-  inunctions. 


Tab.  M 


I 


M 


J 


LUh.  Anst  /:'  Rmhhold,,  Muiichen. 


PLATE    35. 

Proliferating  Papules  on  the  Labia  Majora,  in  the  Qenito- 
crural  Fold,  and  on  the  Perineum  as  far  as  the  Anus. 

S.  M.,  24  years  old,  seamstress ;  admitted  May  15,  1896. 
Proliferating,  rapidly  growing,  inflammatory  papules  at  the 
edges  of  the  labia  majora  and  in  the  anal  folds;  similar  but 
smaller  ones  on  the  Ijuttocks  and  the  inner  surfaces  of  the 
thighs.  The  papules  are  moist,  but  only  a  few  present  signs  of 
degeneration  and  suppuration,  so  that  this  form  is  characterized 
chiefly  by  its  inflammatory  nature  and  rapidity  of  growth. 

In  addition,  the  patient  is  suffering  from  a  vaginal  discharge ; 
the  inguinal  glands  are  swollen,  and  the  mucous  membrane  of 
the  isthmus  of  the  fauces  is  diseased. 

Treatment. — Labarraque's  solution  locally.    Inunctions. 


iH').    ou. 


3 


/k^ 


LUiu  Aiist  tl  ReieMwld,  Munch  en 


PLATE    86. 
Proliferating  Papules  on  the  Labia  Majora,  on  the  Peri- 
neum, and  about  the  Anus. 

G.  A.,  20  years  old;  admitted  Dec.  19,  1896.  Patient  says 
she  has  been  ill  for  two  weeks. 

Present  Condition. — Raised  papules,  eroded  at  the  surfjice, 
some  isolated,  others  coalescent,  on  both  labia  majora,  and 
extending  downward  over  the  perineum  to  the  anus.  In 
places  the  proliferations  are  raised  as  much  as  J  cm.  above  the 
surrounding  level,  and  of  a  hard  though  elastic  consistence. 
Inguinal  glands  much  enlarged,  the  remaining  glands  of  the 
body  only  moderately  so.     Leukoplasia  of  the  neck. 

Cured  by  local  application  of  Labarraque's  solution  and 
inunctions  (twenty). 


Tab.  36. 


LUh .  Anst  F.  Rfichhoiri   '  '■  ■ 


PLATE    37. 
Hypertrophic  Papules  and  Folds  about  the  Anus. 

J.  T.,  22  years  old,  hiborer;  admitted  July  18,  1897.  Patient 
has  been  treated  twice  for  papules  on  the  genitalia  and  has  had 
altogether  thirty-seven  inunctions.  Noticed  the  present  trouble 
three  weeks  ago.     Says  he  had  his  last  coitus  in  Sei)t.,  1896. 

Present  Condition. — Numerous  livid,  infiltrated  folds  about 
the  anus.  Close  to  these  large,  dry  syphilitic  proliferations,  of 
about  the  size  of  a  walnut,  hard,  iri'egularly  wrinkled.  In  the 
anal  fold  and  on  the  buttocks  are  also  smaller,  moist  papules  on 
a  level  with  the  skin. 

The  patient  looks  very  much  neglected,  is  covered  with  a 
tertiary  macular  syphilide,  the  glands  of  the  body  are  swollen, 
and  the  mucous  membrane  of  the  throat  is  diseased. 

Cured  by  thirty  inunctions. 


'It.  .i,/.>/  /.  Heuhkold,.  Mimd\en. 


PLATE   38. 

Old  Annular  Papules  that  have  begun  to  Heal  in  the 
Center. 

T.  R.,  17  years  old,  servant-girl;  admitted  July  29,  1897. 
Patient  says  she  was  treated  a  year  ago  in  the  hospital  for 
a  disease  of  the  genitals  which  she  is  unable  to  describe  in 
detail.     Her  present  attack  began  two  luonths  ago. 

Present  Condition. — The  labia  niajora,  with  their  prolonga- 
tions as  far  as  the  anus,  and  both  groins  are  thickly  covered 
with  partly  isolated  and  partly  coalescent  papules.  Here  and 
there,  owing  to  regeneration  of  the  central  portion,  the  patches 
are  converted  into  circular  wreaths  as  large  as  a  penny,  raised 
above  the  level  of  the  skin,  with  a  dark-brown  pigmentation 
in  the  center;  or  the  inner  margin  of  the  wreath  is  degen- 
erated at  the  surface,  while  the  center  is  covered  with  whitish- 
gray  scar-tissue.  The  inguinal  glands  are  swollen.  On  the 
front  of  the  legs  and  on  the  back  and  buttocks  are  seen  a 
number  of  flat,  pigmented  spots  as  large  as  peas.  In  the 
right  supraclavicular  region  is  a  light-brown  pigmented  area 
about  as  large  as  a  dollar,  with  here  and  there,  about  the 
periphery,  a  few  slight  papular  elevations.  Cervical  glands 
moderately  swollen.  Leukoplasia  of  the  neck.  Mucous  mem- 
brane of  the  mouth  intact. 

Treatment. — Antiseptic  mouth-wash.  Baths.  Inunctions. 
After  twenty-five  inunctions  the  circular  groups  of  papules  are 
seen  to  be  converted  into  dark,  reddish-brown,  pigmented  areas 
corresponding  in  distribution  to  the  specific  eruption.  Inguinal 
glands  shrunken. 


M^/^, 


$ 


^ 


PLATE   39. 

Diphtheritic  Papules  on  the  Mucous  Membrane  of  the  Os 
Uteri  and  Vagina. 

M.  A.,  50  years  old,  charwoman. 

The  OS  presents  fissures  and  contracted  scars,  the  result  of 
former  parturitions.  A  number  of  discolored  ulcers,  sur- 
rounded by  inflammatory  tissue,  are  seen ;  two  on  the  anterior, 
one  on  the  posterior  lip,  and  several,  partly  coalescent,  on  the 
posterior  wall  of  the  vagina.  The  patient  is  not  aware  of  the 
ulcers  in  the  vagina  and  os  uteri. 

Isolated,  moist  papules  are  seen  on  the  labia,  in  both  inguinal 
regions,  on  the  perineum,  and  on  the  inner  surfaces  of  both 
thighs.  On  the  trunk  and  neck  a  pustular  syphilide,  mingled 
with  papules.  The  inguinal  as  well  as  all  the  other  glands  of 
the  body  are  enlarged. 

Patient  has  passed  the  climacteric ;  she  says  she  has  noticed  a 
discharge  and  the  "  ulcers  "  for  the  last  two  weeks.  She  has 
given  birth  to  seven  children,  the  last  one  eighteen  years  ago. 

Sublimate  was  applied  locally  to  the  genitals,  and  the  patient 
was  subjected  to  nine  inunctions  and  twenty  injections,  as  a 
general  treatment.  After  being  under  treatment  eighty-seven 
days  she  was  discharged  cured. 

This  case  dates  back  to  the  time  when  the  author  was  assist- 
ant in  Siegmund's  clinic,  1879-80. 


Tab.  39. 


/,///( . ,  I  ns,'  t:  Heuhtwlxt.  Muiirheii . 


PLATE  40. 

Diphtheritic  Papules  on  the  Mucous  Membrane  of  the 
Upper  Lip  and  Left  Side  of  the  Mouth. 

T.  A.,  33  years  old,  tanner;  admitted  Nov.  12,  1896.  The 
patient  was  treated  a  year  ago  for  syphilis.  The  ulcers  on  the 
scrotum  and  in  the  mouth  made  their  appearance  fo'ar  weeks 
ago. 

Present  Condition. — In  the  mucous  membrane  of  the 
upper  lip  and  of  the  cheek  near  the  left  angle  of  the  mouth, 
and  on  the  tonsils,  are  several  discolored  papules,  with  deep, 
ulcerated  centers.  Remnants  of  papules  on  the  palms  of  the 
hands.  Partly  healed  papules  on  the  penis,  scrotum,  and 
buttocks.  On  the  trunk  and  extremities  l)ro\vn  pigmented 
papules  in  pi'ocess  of  regeneration.  General  glandular  enlarge- 
ment. 

Treatment.  —  Sublimate  mouth-wash.  Labarraque's  solu- 
tion externally.    Cured  after  twenty-five  inunctions. 


Tab.  40. 


''     '  '.v/,  /•:  Hpicfuunii  .'ifuni/wii 


PLATE  41a. 

Infiltration  and  Superficial  Necrosis  of  the  Mucosa  and 
Submucosa  of  the  Upper  Lip. 

K.  T.,  70  years  old,  workman  in  a  gas-factory ;  admitted  Aug. 
11,  1896.  Patient  noticed  the  swelling  on  the  upper  lip  for  the 
first  time  in  May  of  last  year.  He  says  he  was  never  sick 
before ;  denies  syphilitic  infection. 

Present  Condition. — About  the  middle  of  the  upper  lip  an 
elliptical  infiltration  about  as  large  as  a  half  dollar,  the  long 
axis  corresponding  with  that  of  the  lip.  At  the  left  extremity 
a  fissure  about  5  mm.  wide  and  5  cm.  long.  The  submaxillary 
glands  can  be  felt  on  both  sides,  but  not  the  parotid  lymphatic 
glands.  The  lymph-glands  of  the  rest  of  the  body  but  little 
affected. 

Treatment. — Inunction.    Cured  after  twenty  applications. 


PLATE  41b. 


Ulcerating  Papules  and  Incipient  Leukoplasia  of  the 
Tongue. 

P.  P.,  49  years  old.  Has  been  treated  as  an  out-patient.  The 
patient  says  that  four  years  ago  she  noticed  fiery-red,  isolated 
nodules  on  the  tongue  for  the  first  time.  Various  remedies 
were  tried,  among  them  cauterization  (with  lunar  caustic), 
which  caused  the  nodules  to  disappear  for  a  time,  but  they 
always  recurred.  A  year  ago  they  again  appeared,  and  the 
patient  underwent  twenty  inunctions,  whereupon  the  eruption 
subsided.  Two  months  ago  the  nodules  began  to  develop 
again,  and  with  them  whitish,  coalescent  ulcers. 

Present  Condition. — The  tongue  is  only  slightly  swollen ; 
at  the  back  the  papill*  are  still  intact ;  the  front  is  smooth  and 
covered  for  the  most  part  with  a  cloudy,  whitish  layer  of  epi- 
thelium. A  discolored,  slightly  raised  ulcer  extends  across  the 
tongue  and  along  both  margins,  while  a  similar  ulcer,  as  large 
as  a  pea,  occupies  the  tip  of  the  tongue  a  little  to  the  left  of  the 
center.  The  ulcers  are  slightly  raised  above  the  surface  and 
surrounded  by  a  sharply  defined  inflammatory  border. 

The  submaxillary  glands  are  hard  and  moderately  swollen. 
Painful  mastication. 

After  the  patient  had  been  treated  for  eight  days,  scar-forma- 
tion began  m  the  middle  of  the  ulcer,  which  was  finally  con- 
verted mto  a  whitish,  epithelial  hyperplasia. 


Tab.  41, 


jm         ^ 


X 


I 


h*\ 


J 


PLATE  42a. 
Elevated,  Coalescent  Papules  on  the  Hard  Palate. 

R.  S.,  21  years  old,  prostitute ;  admitted  Nov.  16,  1896.  The 
patient  was  first  infected  in  1893,  and  has  since  been  treated 
nine  times  for  syphihs.  Most  of  the  relapses  consisted  in  papu- 
lar eruptions  on  the  genitals.  The  present  attack  first  attracted 
the  patient's  notice  two  weeks  ago. 

On  the  hard  palate,  stretching  from  the  fossa  behind  the  in- 
cisors to  the  soft  palate,  is  a  coalescent  group  of  mulberry-like 
proliferations  of  hard,  yet  elastic  consistence,  somewhat  lighter 
in  color  than  the  slightly  inflamed  mucous  membrane  of  the 
surrounding  parts.  The  edges  of  the  soft  palate  and  uvula  are 
slightly  thickened  and  distorted  as  the  result  of  a  former  attack 
of  the  disease,  which  even  now  betrays  itself  by  an  infiltration 
on  the  edge  of  the  soft  palate  and  uvula.  The  vibrations  of 
the  pillars  of  the  fauces  during  phonation  are  sluggish  and 
irregular.  Concomitant  symptoms  are  found  in  flat,  glistening 
papules,  as  large  as  a  bean,  on  the  labia  majora,  and  in  a  gen- 
eral glandular  enlargement. 

Treatanent. — Inunctions.  The  specific  infiltrations  disap- 
peared, the  proliferations  on  the  hard  palate  subsided,  and  the 
mobility  of  the  pillars  became  almost  normal. 


PLATE   42b. 
Leukoplasia  (Psoriasis)  Linguae. 

C.  J.,  49  years  old.  Under  treatment  for  emphysema  and 
pulmonary  catarrh  in  Ward  No.  12. 

The  patient  has  had  various  diseases.  In  1872  or  1873  he 
acquired  a  hard  chancre,  which  was  followed  by  eruptions  on 
the  skin  and  sores  in  the  mouth.  With  the  exception  of  local 
remedies  and  river-baths  the  patient  did  not  undergo  any  treat- 
ment for  his  disease.  Lunar  caustic,  gargles,  and  precipitate 
ointments  were  the  local  remedies  he  employed. 

The  patient  used  to  be  a  heavy  smoker;  when  he  worked 
on  a  freight  train  he  used  to  smoke  both  cigars  and  pipe 
day  and  night.     In  1891  he  noticed  for  the  first  time  whitish 


Tab.  42. 


Lith.Arvii  r.  tieia 


vesicles  on  the  tongue,  which  bled  when  they  were  opened 
with  a  pin.  The  present  condition  of  the  tongue  the  patient 
says  he  has  noticed  for  the  last  eighteen  months.  He  is  thin, 
but  not  cachectic. 

Present  Condition. — The  tongue  is  not  perceptibly  swollen ; 
but  the  patient  can  only  protrude  it  a  little  and  with  difficulty. 
The  surface  is  white,  moderately  thickened,  and  divided  into 
irregular  islands  by  shallow  grooves.  These  grooves  do  not 
appear  to  be  due  to  conti'acting  scars,  but  rather  to  correspond 
to  tlie  normal  furrows  in  the  tongue.  On  the  other  hand,  the 
islands  appear  slightly  raised,  owing  to  the  thickening  of  the 
epithelium  and  the  moderate  inflammation  which  preceded 
their  formation,  and  which  the  patient  described  as  blisters. 
The  tongue  does  not  feel  hai'd,  and  in  its  present  condition  is 
not  painfi;].     All  delicate  tactile  sensibility  is  lost. 

The  chewing  of  highly  seasoned  food  or  sharp  pieces  of 
bread  is  apt  to  produce  fissures,  which,  however,  heal  of  their 
own  accord  in  a  few  days.  The  epithelium  of  the  buccal 
mucous  membrane  opposite  the  alveolar  border  is  also  some- 
what cloudy,  but  not  as  thick  as  that  of  the  tongue. 

Submaxillary  glands  are  not  swollen.  No  demonstrable 
syphilitic  symptoms. 


PLATE    43a. 
Condylomatous  Iritis. 

L.  P.,  23  years  old,  footman ;  admitted  Nov.  30,  1896.  The 
patient  complains  of  pains  in  the  right  temporal  regiozi,  and 
tearing  pains  in  the  right  eye  for  the  past  five  days.  The  lids 
of  the  diseased  eye  were  adherent;  lachrymal  secretion  very 
ahundant.     Syphilis  denied. 

Present  Condition. — Ciliary  congestion  of  the  right  eye. 
Cornea  and  aqueous  chaniher  normal ;  pupil  dilates  in  the  form 
of  a  kidney  upon  application  of  atropin,  owing  to  a  sharp 
synechia  at  the  external  inferior  portion.  From  the  inferior 
pole  of  the  external  quadrant  a  reddish  tumor  as  large  as 
a  hemp-seed  projects  into  the  pupil.  On  the  raph^  of  the 
penis,  ahout  the  middle  of  the  pendulous  portion,  is  a  moder- 
ately infiltrated,  pigmented  scar  of  a  livid  coppery  hue,  about 
as  large  as  a  bean.  Multiple,  iiKlolent  swelling  of  inguinal, 
axillary,  and  cervical  glands.  The  trunk  is  covered  with  a 
diffuse  syphilide  consisting  of  small  pustules. 

Palms  of  the  hands,  soles  of  the  feet,  and  buccal  mucous 
membrane  intact. 

Subconjunctival  injections  of  sublimate.    Inunctions.    Cured. 


PLATE    43b. 
Qummatous  Tarsitis  of  the  Left  Eye.    Trachoma. 

E.  H.,  24  years  old  ;  admitted  Nov.  14, 1895.  The  woman  has 
been  suffering  from  trachoma  for  several  years.  Three  years 
ago  she  contracted  syphilis  and  had  a  rash  on  the  entire  body, 
for  which  she  underwent  an  inunction  cure.  For  the  past  week 
she  hills  felt  a  tumor  under  the  left  upper  eyelid. 

Present  Condition. — Tlie  patient  is  pale  and  delicately  built ; 
lymph-glands  generally  are  enlarged.  Front  and  back  of  the 
neck  covered  by  a  typical  leukoplasia.  Both  tonsils  are  enlarged 
and  fissured. 

Condition  of  left  eye :  the  conjunctiva  of  the  lower  lid 
presents  various  alterations  due  to  trachoma.  A  tumor  about 
as  large  as  an  almond  can  be  felt  through  the  upper  lid. 
Tarsal  conjunctiva  velvety  and  deejily  injected.  The  con- 
junctiva over  the  convex  border  of  the  tarsus  and  the  inter- 
mediate portion  is  converted  into  a  brawny  wheal,  which 
merges  internally  into  the  slightly  infiltrated  semilunar  fold. 
About  the  center  of  the  w'heal  is  a  shallow  ulcer,  about  as  large 
as  a  pea,  with  grayish-white,  discolored '  floor  and  indurated 
margin. 

Treatment. — Inunctions.  Potassium  iodid  internally.  Cured 
after  thirty  inunctions. 


Tab.  43. 


PLATE    44,  44a,  45. 
Syphilitic  Frambesia  (Yaws).    5yphilis  Prsecox. 

J.  R.,  25  years  old,  prostitute;  admitted  April  6,  1896.  In 
April,  1895,  the  patient  was  treated  for  a  soft  chancre  on  the 
genitals.  In  October,  1895,  she  acquired  a  hard  chancre  on 
the  right  labium  majus;  a  short  time  afterward  an  eruption 
appeared.  The  patient  was  subjected  to  thirty-five  inunctions. 
Present  attack  began  four  weeks  ago. 

Present  Condition. — On  the  hairy  scalp  (Plates  44,  44a, 
45)  are  several  papillomatous,  warty  excrescences  as  large  as 
a  half  dollar,  covered  with  scales  and  crusts.  Serpiginous 
ulcerations  on  the  cartilage  and  left  ala  of  the  nose,  on  the 
right  upper  arm,  below  the  left  mamma,  and  on  the  back ; 
here  and  there  on  the  trunk  a  few  papular  infiltrations. 

Fig.  45  represents  the  same  case  :  Mulberry -like  proliferations 
on  the  hairy  scalp  after  the  crusts  have  fallen  oflT. 


Tab.  44  a. 


PLATES    46,  4Ga,  47. 

Gummatous  Ulcers  on  the  Labia  Majora,  the  Posterior 
Commissure,  the  Right  Labium  Minus,  and  the  Vagina. 

W.  A.,  26  years  old,  servant-girl;  admitted  June  15,  1896. 
She  has  been  syphilitic  since  1890,  and  is  now  undergoing  treat- 
ment for  the  third  time  in  this  hospital ;  the  first  attack  occurred 
in  1890,  the  second  in  the  latter  part  of  1892.  The  present  at- 
tack began  only  a  few  weeks  ago,  so  that  the  patient  has  been 
free  from  any  noticeable  syphilitic  symptoms  forthree  and  a  half 
years. 

Both  labia  majora,  the  clitoris,  and  the  labia  minora  are 
hypertrophied ;  their  consistence  not  perceptibly  increased. 
At  the  margin  of  the  left  labium  majus  are  three  circular 
ulcers  as  large  as  a  bean ;  at  the  margin  of  the  right  (Plates 
46,  46a),  two  about  twice  as  large,  and  on  the  posterior  com- 
missure two  still  larger  ones,  separated  by  a  narrow  bridge  of 
tissue.  These  ulcers  have  sharply  defined  edges;  the  base  is 
irregularly  degenerated,  and  they  are  for  the  most  part  covered 
with  pus.  Similar,  smaller  ulcers,  to  the  number  of  about 
eleven  are  found  on  the  external  surface  of  the  right  labium 
minus,  in  the  vestibule,  and  about  the  middle  of  the  vaginal 
canal.  Tliey  have  the  same  degenerated  base,  but  are  neither 
as  large  nor  as  deep  as  the  others  (PI.  47). 

At  the  right  angle  of  the  os  is  a  discolored  ulcer,  larger  than 
a  bean.  The  inguinal  glands  on  both  sides  are  palpable  and 
spindle-shaped.  Pigmented  scars  on  the  legs,  and  here  and 
there  on  the  trunk. 

Treatment. — The  ulcers  were  sprinkled  with  iodoform  pow- 
der. Twenty-four  grains  of  potassium  iodid  per  diem.  After 
a  month  most  of  the  ulcers  had  healed.  The  labia  were  still 
enlarged.  The  patient  had  improved  a  good  deal,  and  an 
inunction  treatment  was  ordered.  Cured  after  twenty  inunc- 
tions. 


Tab.   4(3. 


Lt!h .  AnM  /  ReuhhoUL.  Miiiuheii 


Tab.  46  a. 


PLATE    48a. 
Qutntnatous  Ulcer  of  the  Left  Nipple. 

H.  R.,  26  years  old,  drummer ;  admitted  Oct.  9,  1896.  Pa- 
tient has  been  suffering  from  syphilis  for  six  months,  and  has 
been  almost  constantly  under  mercurial  treatment  during  that 
time ;  in  spite  of  that,  liowever,  the  entire  body  became  covered 
with  ulcers,  to  the  number  of  seventy-four.  He  is  also  suffer- 
ing from  an  affection  of  the  left  elbow-joint. 

Present  Condition. — The  left  nipple  is  replaced  by  an 
ulcerating  sore ;  the  areola  is  swollen  and  converted  into  a 
deep  infiltration.  On  the  hairy  scalp  are  several  pustular  sores 
covered  with  crusts.  In  the  right  nostril  a  fissure,  with  infiltra- 
tion of  the  base  and  ala  of  the  nose.  On  the  root  of  the  penis 
a  broad  scar  from  the  sclerosis.  Numerous  partly  healed  sores 
and  pigmented  and  desquamating  scars,  the  remains  of  the 
above-mentioned  sores,  are  scattered  over  the  entire  body.  The 
patient  is  emaciated  and  anemic;  he  complains  of  lassitude 
and  headache. 

Treatment. — Decoctum  Zittmann.'    Inunctions. 

'  Decoctum  sarsaparillae  compositum  (sarsaparilla.  senna,  glycyrrhiza, 
fennel  and  anise,  with  calomel,  cinnabar,  and  ahim). 


PLATE   48b. 
Gumma  of  the  Breast. 

C.  P.,  41  years  old,  charwoman  ;  admitted  May  28, 1897.  For 
the  past  year  the  patient  has  noticed  a  tumor  in  the  left 
breast,  which  gradually  grew  larger  and  began  to  ulcerate  last 
fall.  She  says  she  has  always  been  well  otherwise.  She  has 
borne  four  liAnng  children ;  has  never  nursed ;  never  had  an 
abortion. 

Present  Condition. — In  the  outer  half  of  the  left  mammary 
gland  are  a  number  of  old  and  recent  scars,  which  palpation 
shows  to  be  due  to  infiltrated  bands  of  tis.*ue,  radiating  over 
the  gland  almost  as  fiir  as  the  left  margin.  About  the  anus,  on 
the  perineum,  and  on  the  posterior  surface  of  the  labia  majora 
the  marks  of  old  papules,  surroimded  by  a  red  halo.  Multiple 
swelling  of  the  inguinal  glands  on  both  sides,  and  also  of  the 
epitrochlear  and  axillary  glands.     Mouth  and  throat  intact. 

Treatment. — Potassium  iodid,  24  grains  per  diem.  Gray 
plaster. 


Tab.  48. 


LUh .  AnsI  t'.  Reichhold.  Miinchen. 


PLATE  49. 
Syphilitic  Rupia. 

R.  M.,  46  years  old,  waiter's  wife;  admitted  June  12,  1896. 
With  the  exception  of  varicella  in  her  twenty-second  year,  the 
patient  says  she  has  never  had  any  disease. 

Five  or  six  years  ago  the  patient  suffered  from  violent  head- 
ache; two  years  ago  she  had  an  ulcer  on  her  leg.  Patient  had 
borne  twice,  in  her  twenty-fourth  and  in  her  twenty -seventh 
year  (out  of  wedlock) ;  the  children  lived  for  some  time ;  no 
abortion.  Venereal  disease  denied.  Patient  is  a  heavy 
drinker. 

Ulcers  first  appeared  on  the  arms  four  months  ago. 

Present  Condition.— Patient  is  very  much  emaciated.  On 
the  left  arm,  above  the  elbow,  an  oval  group  of  infiltrations, 
covered  for  the  most  part  with  rupia-like  scabs.  The  scars  are 
only  skin-deep.  About  the  periphery,  especially  at  the  upper 
part,  some  desquamation  of  the  epidermis. 

In  two  places  recent,  superficial  infiltrations  are  seen,  over 
which  the  skin  is  raised,  forming  two  cloudy  blisters. 

On  the  right  arm,  extending  below  the  elbow,  a  semicircular 
group  of  similar  sores,  some  of  them  already  converted  into 
scars,  some  still  covered  with  rupia-like  scabs,  and  some  quite 
recent,  resembling  blisters.     General  glandular  enlargement. 

Whitish  scars  are  seen  in  the  left  groin  and  at  the  edge  of 
both  labia  majora. 

Internal  organs  normal,  with  the  exception  of  an  old  process 
at  the  apex  of  the  right  lung. 

After  the  scabs  had  fallen  off,  round  and  oval  ulcers  appeared 
in  the  affected  areas,  penetrating  the  skin  and  covered  with 
pus. 

Scar-tissue  began  to  form  after  the  ulcers  had  been  treated 
with  red-precipitate  ointment  for  two  weeks,  and  iodid  of  iron 
had  been  given  internally.  With  the  exception  of  a  slight  red- 
ness at  the  site  of  the  ulcers  nothing  abnormal  in  the  skin. 


Tab.  49. 


^^^fcir- 


Lith-  Anst  E  Reichhold,  Miimhen . 


PLATES  50,  r)Oa. 
Serpiginous,  Qummy  Ulcers. 

F.  P.,  28  years  old;  admitted  Feb.  10,  1896.  The  patient 
became  infected  with  sypliilis  in  her  eighteenth  year,  and  was 
at  tliat  time  treated  with  inunctions.  She  had  no  rehrpses 
until  tifteen  months  ago,  when  a  tumor  began  to  make  its 
appearance  in  the  lateral  cervical  region,  and  was  followed  by 
tumors  in  other  parts  of  the  body,  all  of  which  softened  and 
broke  down.  The  ulcerations  were  cured  by  inunctions,  leav- 
ing scars. 

The  ulcers  now  seen  on  the  right  thigh  and  on  the  left  leg 
developed  six  weeks  ago. 

Present  Condition. — There  are  no  alterations  in  the  genitals 
at  the  present  time.  The  glands  in  general  are  enlarged.  On 
the  trunk  and  extremities  are  seen  numerous  scars  of  varying 
size,  some  pigmented,  some  white,  which,  from  their  shape, 
evidently  represent  the  remains  of  serpiginous  ulcerations. 
Here  and  there,  especially  in  the  mammary  region,  along  the 
costal  margin,  over  the  head  of  the  right  humerus,  on  the 
flexor  and  extensor  surfixces  of  the  left  upper  arm,  on  both 
sides  of  the  neck,  and  over  the  eyebrows  localized  eruptions 
are  seen.  The  papules  are  livid  red,  distinctly  raised  alxne  the 
level  of  the  skin  ;  the  edges  are  everted  and  covered  with  sev- 
eral superjacent,  dirty  brown  scabs,  some  of  which,  especially 
on  the  left  arm,  attain  the  size  of  a  penny  (see  Plate).  The 
center  is  occupied  by  white  and  brown  scars;  as  they  approach 
the  periphery  the  color  changes  to  a  reddish  hue,  the  scars 
become  puckered,  and  finally  merge  into  a  raised  zone  of  infil- 
tration. This  infiltrated  margin  is  composed  of  single  nodules, 
closely  crowded  together  and  merging  into  one  another.  A 
few  of  the  nodules  are  covered  with  very  thin  crusts  and  scales ; 
the  older  ones,  on  the  other  hand,  are  covered  with  several 
layers  of  crusts.  On  the  lower  third  of  the  left  leg  is  a  sharply 
circumscribed  ulcer,  about  as  large  as  a  ])enny,  with  discolored 
floor.  On  the  inner  margin  of  the  right  thigh,  above  the  knee, 
another  similar  ulcer. 

The  mucous  membrane  of  mouth  and  throat  is  intact. 

Treatment. — Local  application  of  white-precipitate  oint- 
ment; inunctions  of  ^jss  ung.  ciner.  The  skin-lesions  disap- 
peared rapidly.  Patient  was  discharged  before  the  end  of  the 
cure,  at  her  urgent  request. 


l.Uh.  An.s/  E Reichhold,  Miinche/i. 


Tab.  50  a. 


PLATE  51. 
Serpiginous,  Gummy  Ulcers  of  the  Right  Calf. 

P.  T.,  30  years  old  ;  admitted  April  20,  1896.  Four  years  ago 
the  patient  contracted  a  disease  from  her  husband,  who  was  then 
suffering  from  an  eruption.  The  disease  began  in  the  left  ton- 
sil. The  cervical  glands  became  swollen  ;  later  she  was  troubled 
with  an  eruption  and  with  headache.  Since  that  time  the 
patient  was  several  times  treated  for  various  manifestations  of 
the  disease,  but  never  continuously.  Eleven  months  ago  she 
began  to  notice  nodes  on  the  calf  of  the  left  leg,  which  soon 
ulcerated.  She  has  had  seven  children  ;  the  last  one  was  born 
at  term,  but  she  says  it  is  afflicted  with  an  eruption. 

Present  Condition  — On  the  calf  of  the  right  leg  is  a  group  of 
typical,  serpiginous,  gummy  infiltrations  and  ulcers,  surround- 
ing a  central  scar,  the  remains  of  old  ulcers ;  about  the  periph- 
ery circular  and  elliptical  ulcers  of  varying  size,  with  fairly 
W'ell-defined  edges  and  the  base  covered  w'ith  granulations  and 
detritus.  Similar  ulcers  are  seen  above  the  left  knee.  In  the 
right  groin  and  on  the  right  labium  majus  the  remains  of  infil- 
trations and  the  scars  of  papules  can  still  be  seen.  Some  slight 
pigmentation  can  be  made  out  on  the  trunk  and  extremities. 
The  inguinal  glands  are  only  slightly,  the  cervical  glands  typic- 
ally enlarged. 

A  cure  was  effected  by  local  applications  of  red-precipitate 
ointment,  internal  administration  of  potassium  iodid,  and  a 
course  of  twenty-one  inimctions. 


Tab.  51. 


LUh.  Afisl  F.  Retdihtilfl,  Miinchen. 


PLATE  52. 

Cutaneous  Qumma  on  the  Dorsum  of  the  Foot.    Gumma  of 
the  Pharynx. 

B.  M.,  37  years  old,  married ;  admitted  Dec.  19,  1895.  Said 
to  have  had  a  nasal  voice  ever  since  her  eighth  year.  Nothing 
in  the  history  has  any  special  bearing  on  the  origin  of  the  dis- 
ease. The  patient  has  had  six  children,  all  of  whom  died  in 
infancy  from  intercurrent  diseases. 

Present  Condition. — The  soft  palate  and  uvula  are  entirely 
wanting,  so  that  the  nasopharj'ngeal  cavity  extends  high  up 
into  the  roof  of  the  mouth.  The  posterior  wall  of  the  pharynx 
presents  a  yellowish,  discolored,  ulcerated  area  about  as  large 
as  a  penny. 

On  the  dorsum  of  the  right  foot,  corresponding  in  position  to 
the  fourth  and  fifth  metatarsophalangeal  articulations,  is  an 
ulcer  as  large  as  a  dollar,  filled  with  proliferating  granulations. 
The  edges,  where  they  exist,  are  sharply  defined  and  over- 
hang the  mass  of  granulations,  so  that  a  probe  can  be  inserted 
2  to  4  mm.  under  the  undermined  edges.  The  ulceration  ex- 
tends down  to  the  sheaths  of  the  tendons,  although  the  mova- 
bility  of  the  toes  is  unimpaired. 

The  case  was  treated  surgically. 


PLATE   52a. 
Ulcerative  Gummata  of  the  Pericranium. 

K.  E.,  50  years  old,  pauper.  The  patient  has  been  treated 
repeatedly  in  a  ward  during  the  last  three  years  for  severe 
syphilitic  manifestations. 

On  the  right  parietal  bone  is  a  depression  as  large  as  a  dollar, 
at  the  bottom  of  which  the  bone  is  exposed.  The  soft  parts 
about  the  periphery  of  the  ulcer-sore  are  loosened.  On  the 
right  frontal  bone  is  a  similar,  smaller  swelling  about  as  large 
as  a  penny,  and  a  third  one  is  seen  on  the  occiput.  There  is 
also  a  periosteal  gumma  on  the  right  tibia.  The  patient  is 
very  weak  and  emaciated,  and  has  edema  in  the  lower  ex- 
tremities. 


Tab.  02. 


f 


Ait/i.Af/st.  F.  Reif/ihoM.  Miinchen. 


By  careful  local  treatment  and  general  tonics  the  gunmiata 
were  gradually'  absorbed  after  four  months'  treatment.  The 
one  on  the  forehead  healed  in  such  a  manner  that  the  integu- 
ment united  and  the  bone  was  covered  by  granulation-  and 
scar-tissue. 


Tab.  52  a. 


PLATE   53. 

Gumma  in  the  Glands  of  the  Neck,  with  Destruction  of 

the  Integument. 

B.  K.,  32  years  old,  servant-girl;  admitted  Oct.  5,  1895. 
There  is  no  history  of  hereditary  disease.  Patient  says  she 
occasionally  suffers  from  nocturnal  headache.  Two  years  ago 
she  was  treated  in  a  throat  clinic,  and  a  year  ago  in  a  surgical 
clinic  for  an  ulcer  on  one  of  the  lower  extremities.  Has  never 
been  subjected  to  a  general  antisyphilitic  treatment  and  denies 
any  knowledge  of  the  disease. 

Present  Condition. — The  patient  is  well  nourished,  some- 
what pale.  Internal  organs  normal ;  has  never  been  pregnant; 
menstruation  regular. 

No  alterations  can  be  made  out  on  the  external  labia  or  in 
the  rest  of  the  genitals.  The  skin  of  the  neck  and  throat  is 
the  seat  of  a  typical  leukoplasia.  On  the  external  surface  of 
the  left  calf  a  circular,  depressed  atrophic  scar ;  above  the  left 
external  malleolus  a  scar  measuring  about  2  square  cm.,  adher- 
ent to  the  bone,  with  irregular,  circular,  and  elliptical  margin. 
The  soft  palate  and  uvula  partly  destroyed  and  disfigured  by 
scars. 

The  inguinal  glands  are  hard,  and  present  a  multiple  swell- 
ing; the  axillary  glands  on  both  sides  are  even  more  distinctly 
enlarged,  those  above  the  bend  of  the  elbow  only  slightly  so. 

All  the  glands  in  the  neck,  especially  those  in  the  left  sub- 
maxillary and  supraclavicular  regions,  are  swollen  to  the  size 
of  pigeons'  eggs  and  hard  and  resistant  to  the  touch.  Two 
elliptical  ulcers  about  1  cm.  long,  corresponding  to  a  submaxil- 
lary and  a  supraclavicular  gland,  are  seen  on  the  left  side  of  the 
neck  ;  the  ulcers  have  broken  through  the  skin  ;  the  edges  are 
steep ;  the  floor  of  the  upper  one  is  covered  with  necrotic  tis- 
sue, that  of  the  lower  one  with  yellowish-white  pus.  Over  the 
other  swollen  glands  the  skin  is  loose  and  freely  movable. 

The  patient  received  24  grains  of  potassium  iodid  per  diem  ; 
the  .sores  were  dressed  first  wdth  iodoform  and  later  with  gray 
plaster.  The  ulcers  healed  and  the  glands  were  reduced  in  size, 
BO  that  the  patient  was  discharged  cured  after  thirty-eight  days, 
the  neck  having  regained  its  normal  outline. 


Tab.  53. 


t^ 


O^ 


^J^ 


Lith,An!it.  F.  Reich  hold,  Miinciwfi. 


PLATES   54,   54a. 
Gummatous  Ulcers  of  the  Skin  and  Inguinal  Glands. 

W.  K.,  46  years  old,  tailor;  admitted  Jan.  21,  1895;  died  Jan. 
7,  1896.  In  1892  the  patient  had  an  eruption  covering  almost 
the  entire  body,  most  abundant  on  the  trunk,  for  which  he 
used  a  white  ointment.  The  nature  of  the  disease  was  not 
known  to  him. 

Present  Condition. — Pigmented  and  atrophic  cutaneous 
scars  can  be  seen  on  the  entire  body,  (hie  to  the  above-men- 
tioned eruption.  On  the  inner  aspect  of  the  left  thigh  are  five 
ulcers  ranging  in  size  from  a  penny  to  a  half  dollar,  penetrat- 
ing below  the  skin,  the  base  presenting  some  granulation  and 
much  purulent  necrotic  tissue. 

In  the  groin  is  a  large,  oval  wound,  corresponding  to  a 
broken-down  superficial  gland.  The  other  lymphatic  glands 
are  hard,  but  little  enlarged.  The  patient  is  pale  and  emaci- 
ated ;  he  keeps  the  lower  extremity  flexed  at  the  hip  and  at  the 
knee.  The  joints  themselves  are  unaffected.  His  psychical 
condition  is  normal ;  his  intelligence,  however,  is  of  a  low 
order.  The  gummatous  ulcers  were  not  affected  by  potassium 
iodid  and  local  treatment  with  iodoform,  so  that  inunctions 
were  ordered. 

Mar.  21^.  After  thirty  inunctions  the  wounds  showed  active 
granulation  and  a  border  of  scar-tissue,  but  the  inunctions  had 
to  be  discontinued  on  account  of  severe  gingivitis  and  abnormal 
proliferation  of  the  epithelium  at  the  margin  of  the  tongue 
and  in  the  mucous  membrane  of  the  cheek,  opposite  the  alve- 
olar border.  In  spite  of  careful  nursing  neither  the  ulcers 
themselves  nor  the  general  condition  of  the  pale,  torpid  patient 
improved,  so  that  at  the  end  of  September  the  wounds  were 
but  little  reduced  in  size. 

In  the  beginning  of  October  a  gland  in  the  right  inguinal 
region  became  swollen.  The  integument  became  inflamed  and 
ulcerated,  and  a  thin,  bloody  secretion  was  discharged.  After 
three  weeks  the  wound  improved  somewhat,  so  that  only  a  part 
of  the  degenerated  gland  and  a  slight  granulation  could  be 
seen  in  the  floor  (colored  plate). 

Od.  SI.  Erysipelas  developed  from  the  right  inguinal  fold 
to  the  middle  of  the  thigh  ;  incipient  bed-sore  in  the  right 
sacral  region. 

The  erysipelatous  inflammation  subsided  upon  the  applica- 
tion of  compresses  of  aluminum  acetate  solution  and  with 
proper  care  as  to  diet  and  change  of  position  in  bed ;  but  on 
Oct.  24th  the  patient  still  complains  of  severe  pain  in  the  right 


JO 

•a 


i 


J 


hip,  wliicli  \»  found  to  be  red  and  inflamed.  This  condition  is 
also  reheved  in  six  days  with  sodium  salicylate  internally  and 
cold  compresses. 

Ophthalmoscopic  Examination.  —  Discoloration  of  the 
pupil,  incipient  atrophy. 

The  patient  complains  of  severe  pruritus.  Urine  contains  no 
sugar,  and  only  .small  quantities  of  albumin.  The  sediment 
contains  many  leukocj'tes  and  bladder-epithelium,  but  no 
renal  e  ements. 

Bronchitis  affecting  the  larger  bronchi  of  the  entire  lung. 
The  fever  is  moderate  ;  in  the  morning  it  falls  almost  to  normal, 
in  the  evening  it  rises  to  38.5°  C.  Tlie  patient  gradually  sinks 
into  a  very  low  state,  and  has  to  be  roused  to  take  nourish- 
ment ;  he  barely  understands  what  is  said  to  him  and  immedi- 
ately relapses  into  a  stupid  state.     He  died  Jan.  7,  1896. 

Autopsy. — Body  small,  very  much  emaciated.  In  the  left 
inguinal  region  the  skin  is  destroyed  over  an  area  as  large  as 
the  hand. 

In  the  right  groin  a  similar  ulceration,  about  as  large  as  a 
dollar  ;  on  the  posterior  aspect  of  the  left  thigh  is  a  larger  scar, 
freel}'  movable  over  the  muscle  ;  a  smaller  one  on  the  external 
surface  of  the  left  thigh  and  over  the  head  of  the  fibula. 

The  skull  is  thin,  very  ])rominent  in  the  suboccipital  region. 
The  dura  mater  and  soft  layers  of  the  meninges  present  noth- 
ing abnormal.  The  surface  of  the  brain  is  somewhat  flattened. 
The  cortex  slightly  narrowed.  Brain-substance  edematous. 
Nothing  abnormal  in  the  vessels  at  the  base. 

Both  liiyigs  emphysematous ;  atrophied  (poor  in  substance) ;  no 
adhesions.  The  bronchi  of  the  lower  lobes  contain  a  purulent 
secretion. 

Heart  small  and  contracted ;  subpericardial  layer  presents 
some  fatt}'^  yellow  and  red  discolorations.  Myocardium  yellow- 
ish-brown.    Valves  and  vessels  present  no  alterations. 

Liver  rather  small,  convexity  increased.  The  individual 
lobules  over  the  entire  surface  are  very  prominent,  their  fatty, 
yellow  color  contrasting  with  the  reddish  hue  of  the  interven- 
ing conneclive  tissue.  The  .same  picture  is  presented  in  cross- 
section.  On  the  right  lobe  is  a  yellowisli,  calcified  nodule 
about  as  large  as  a  pea. 

Spleen  enlarged  and  flaccid,  stroma  increased;  a  slight  waxy 
luster  is  seen  on  section. 

Both  kiduey.H  nuich  enlarged,  tough,  the  capsule  easily  re- 
moved. The  surface  has  a  waxy  appearance;  on  section  a  few 
fine  hemorrhagic  points  are  seen;  the  cortex  is  increased  in 
width,  pale  yellow,  in  marked  contrast  with  the  flesh-colored 
pyramids,  and  looks  distinctly  like  bacon.  Pelvis  dilated  and 
filled  with  fluid  containing  dark,  turbid  flakes;  the  mucous 
membrane  discolored  by  numerous  hemorrhages. 


The  bladder  dilated  to  its  utmost,  containing  clear  urine. 
Mucous  membrane  strongly  injected  in  places. 

Orv  the  right  side  of  the  neck  of  the  penis  an  atrophic  scar. 

The  mucous  membrane  of  the  intestine  about  the  anus  is 
puckered  and  thickened,  and  protrudes  from  the  anus. 

Over  the  sacrum  a  large,  irregular  ulcer  extending  chiefly 
toward  the  right  side. 

Diagnosis. — Inveterate  syphilis.  Cirrhosis  of  the  liver  in 
process  of  regeneration.  Amyloid  disease  of  kidneys  and 
spleen.  Atrophy  of  the  heart.  Slight  atrophy  of  the  brain. 
General  anemia  and  marasmus. 


Tab.  54  a. 


PLATE    55. 
Gummatous  Disease  and  Necrosis  of  the  Soft  Parts. 

H.  A.,  29  years  old,  servant-girl ;  admitted  May  9,  1896.  The 
patient  had  diphtheria  and  sniall-pox  when  a  child.  In  her 
eighth  year  she  suffered  with  a  disease  of  the  left  fibula.  The 
disease  in  the  upper  arm  began  a  year  ago.  Her  menses  did 
not  begin  until  she  was  eighteen  years  old ;  has  always  men- 
struated regularly.  The  patient  gave  birth  to  a  child  last  August ; 
the  child  was  weakly  and  died  in  four  weeks  of  a  birthmark,  so 
the  patient  says. 

Present  Condition. — The  patient  is  of  slender  build  and 
emaciated.  Teeth  are  bad.  Nose  slightly  saddle-shaped.  The 
throat  marked  with  scai-s.  The  remains  of  the  soft  palate  are 
drawn  against  the  posterior  wall  of  the  pharynx.  Uvula  is 
wanting. 

There  is  a  radiating,  movable  scar  over  the  acromion  and 
clavicle  on  the  left  side.  It  represents  the  remains  of  an  ulcer- 
ation which  followed  the  patient's  confinement  last  year. 
Shortly  afterward  an  ulceration  developed  on  the  left  upper 
arm  and  lasted  two  months.  The  contracting,  radiating  scars 
which  remain  are  directly  adherent  to  the  bone.  At  the  same 
period  a  stiffness  began  to  show  itself  in  the  elbow-joint.  At 
the  beginning  of  the  present  year,  when  the  disease  on  the 
back  of  the  arm  had  hardly  begun  to  heal,  the  ulcer  on  the 
front  of  the  arm  developed,  and  soon  after  that  the  one  on  the 
upper  third  of  the  forearm  and  in  the  bend  of  the  elbow.  The 
left  arm  is  held  in  extension,  the  hand  in  extreme  pronation. 
Flexure  at  the  elbow  and  supination  much  impaired.  The 
upper  two-thirds  of  the  radius  seem  to  be  thickened,  as  is  also 
the  lower  end  of  the  upper  arm.  The  external  surface  of  the 
upper  arm  is  occupied  by  an  ulcer  9  cm.  long  and  3  cm.  wide, 
about  the  periphery  of  which  a  little  scar-tissue  is  beginning  to 
form,  with  here  and  there  a  few  granulations.  The  floor  con- 
sists of  necrotic  muscle-fibers  lying  lengthwise,  of  a  dirty  yellow 
color  and  surrounded  by  irregular  depressions  which  discharge 
a  scanty  secretion.  Further  down  toward  the  elbow  there  is 
a  raised  wheal,  and  near  its  outer  margin  an  oval  ulcer  about 
2  cm.  in  diameter.    A  bridge  of  scar-tissue  about  IJ  cm.  wide 


Tab.  55 


^j.'L..ULiL  j:.  JisiairujUL,  Mundu'i' 


separates  this  ulcer  from  the  one  above  it.  The  floor  is 
forined  by  the  brownish  necrotic  skin.  The  subcutaneous 
ceUular  tissue,  macerated  with  serum,  is  exposed  for  about 
3  to  4  cm.  from  the  edge  of  the  dry  crust  of  skin.  Below  this 
latter  ulcer,  close  to  the  wheal,  there  is  a  third  ulcer  with 
seropurulent  floor ;  divided  into  two  halves  by  a  bridge  of  skin. 
Finally,  on  the  upper  third  of  the  forearm  and  in  series  with 
this  last-mentioned  double  ulcer,  is  one  about  o  cm.  long,  the 
inner  half  of  which,  lying  toward  the  radius,  is  covered  with 
granulations  and  attached  to  the  radius  by  scar-tissue.  In  the 
outer  half  of  the  ulcer  is  a  fragment  of  skin  on  the  point  of 
desquamation,  and  brownish  subcutaneous  tissue,  resting  on 
a  foundation  containing  a  scant  serous  exudation,  so  that  the 
necrotic  parts  are  easily  movable  over  the  underlying  tissue. 
This  ulcer  lies  between  the  radius  and  the  ulna,  over  the  pro- 
nator radii  teres  muscle,  and  seems  to  have  sprung  originally 
from  the  radius.  In  the  bend  of  the  elbow  is  the  above-men- 
tioned wheal  with  the  two  ulcers  near  its  outer  border.  The 
lower  third  of  the  radius  is  enlarged  from  periostitis ;  the  upper 
part  also  thickened  in  irregular  lines  in  the  long  axis  of  the 
bone.  The  ulna  does  not  appear  to  be  involved  to  the  same 
degree.  On  the  other  hand,  the  entire  lower  third  of  the  upper 
arm,  almost  as  far  as  the  middle,  is  enlarged  and,  with  the 
exception  of  the  large  ulcer  described,  covered  with  scar-tissue. 
In  some  places  the  bone  is  reduced  in  thickness  from  atrophy ; 
in  others  it  is  enlarged  from  periostitis. 

On  the  outside  of  the  left  calf  is  a  scar  10  cm.  long,  adherent 
to  the  bone,  the  result  of  the  above-mentioned  disease  of  the 
fibula.  The  genitals  present  no  alterations.  Several  white, 
atrophic  scars  about  the  aiius  prolmbly  date  from  the  attack 
of  small-pox.  The  inguinal,  sus  well  as  the  other  glands  of  the 
body  are  reduced  in  size. 


PLATE    o6a. 
Destruction  of  the  Soft  Palate  by  Gummatous  Ulceration. 

S.  M.,  25  years  old.  The  patient  does  not  know  how  long  her 
disease  has  lasted.  She  only  began  to  feel  pain  in  the  throat 
three  weeks  ago. 

Present  Condition. — At  the  edge  of  the  labia  majora  sev- 
eral whitish,  hairless,  areolar  scars.  Similar,  reticulated  scars 
about  the  anus  and  in  the  vestibule.  In  addition,  other  scars 
on  the  inner  surface  of  both  labia  minora.  Inguinal  glands 
hard  and  spindle-shaped.  Almost  the  entire  soft  palate  want- 
ing, the  edges  of  the  wound  being  covered  with  shreds  of  ne- 
crotic tissue.  The  ulceration  has  invaded  the  edges  of  the  arch 
of  the  palate,  so  that  the  upper  and  lateral  boundaries  of  the 
isthmus  are  also  involved  in  the  degenerative  process. 

Cured  by  the  application  of  fifteen  inunctions  and  64  g.  (Jij) 
of  potassium  iodid  internally. 


PLATE    56b. 
Gumma  (on  Posterior  Wall  of  Pharynx). 

R.  R.,  39  years  old,  no  occupation ;  admitted  Jan.  "6,  1896. 
History  very  meager.  Patient  has  been  married  eleven  years; 
says  she  has  never  been  pregnant.  For  the  last  three  years  she 
has  been  troubled  with  a  "  nasal  affection  ;"  she  says  the  secre- 
tion has  a  very  offensive  odor.  Regurgitation  of  soft  and  liquid 
food  began  quite  suddenly  a  week  ago.  The  patient's  husband 
admits  tliat  he  was  infected  with  syphilis  three  years  ago. 

Present  Condition. — No  remains  of  a  syphilitic  infection 
can  be  demonstrated  on  the  genitals.  At  the  anus  a  red  scar 
about  as  large  as  a  pea.  Multiple  swelling  of  the  inguinal 
glands. 

The  soft  palate  is  destroyed  and  replaced  by  a  scar;  the 
uvula  is  entirely  wanting.  Strands  of  scar-tissue  are  attached 
to  the  posterior  wall  of  the  pharynx,  on  which  there  is  an  ellip- 
tical ulcer  about  I2  cm.  by  ^  cm.,  its  long  axis  corresponding 
with  that  of  the  pharynx.  The  center  is  depressed  and  partly 
covered  with  a  dry,  black  scab;  near  the  edges  it  is  slightly 
flattened.  To  the  right  of  this  ulcer  the  orifice  of  the  Eu- 
stachian tube  can  be  seen.  Rhinoscopic  and  laryngoscopic 
examination  reveals  no  other  alterations. 

Voice  is  nasal.     The  breath  is  very  fetid. 

Treatment. — Inunctions  and  potassium  iodid. 

After  twenty-five  inunctions  the  ulcer  on  the  posterior  wall 
of  the  pharynx  healed  over  completely  and  was  replaced  by 
scar-tissue. 

Pischarged  Feb.  11,  1897. 


Tab    56. 


A'  Reiddwid,  Miinchvn 


PLATE   57. 
Qummatous  Glossitis. 

A.  F.,  25  years  old,  servant-girl ;  admitted  Oct.  28,  1890.  Vi\- 
der  treatment  one  month.  Second  attack.  Has  had  an  ulcer 
on  the  tongue  for  three  months.  Five  years  ago  the  patient 
was  under  treatment  three  months  in  the  syphilitic  ward  of  the 
Wiedener  hospital  for  a  specific  ulcer. 

Present  Condition. — Ulcer  on  the  right  labium  majus.  No 
other  signs  of  a  former  or  still  existing  syphilitic  attack  either 
on  the  skin  or  in  the  glandular  system.  When  the  mouth  is 
opened  wide  and  the  tongue  well  protruded  a  swelling  is  seen 
covering  the  entire  posterior  half  of  the  left  side.  The  tumor 
is  raised  3  to  4  mm.  above  the  surrounding  surface:  it  is  hard 
to  the  touch  and  extends  through  the  entire  thickness  of  the 
organ  from  its  base  to  about  its  middle.  The  surface  of  the 
tumor  is  traversed  by  an  ulcer  3  cm.  long.  From  the  middle 
of  the  tongue,  extending  almost  to  the  tip,  there  is  another 
tumor  consisting  of  a  number  of  nodular  infiltrations,  showing 
necrotic  decay  in  three  places. 

Treatment.  —  Potassium  iodid.  Antiseptic  mouth-wash. 
On  Nov.  17th  an  inunction  treatment  was  inaugurated.  The 
infiltration  was  absorbed  and  the  idcers  healed.  After  fifteen 
inunctions  the  patient  was  discharged  cured. 


I— 

OS 

H 


PLATE    58. 
Papulopustular  Exanthema.    Hereditary  Syphilis. 

(Obtained  through  the  kindness  of  Dr.  Braun,  of  the  Found- 
ling Asyhnii.) 

S.  K.,  about  4  weeks  old,  weight  5^  pounds ;  admitted  July  8, 
1897.  Marasmus  marked.  Suffering  from  bronchitis  and  in- 
testinal catarrh.  The  skin  is  pale  and  wrinkled,  and  thickly 
covered  with  a  syphilitic  eruption.  The  forehead  and  mouth, 
and  also  the  trunk  and  extremities,  are  the  seat  of  papules 
with  pale-red  border,  or  vesicles  containing  a  small  quantity  of 
serous  exudate,  with  flaccid,  partly  degenerated  epidermis. 
Died  after  twenty-four  hours. 

Autopsy. — General  tabes,  bronchitis,  lobular  pneumonia  on 
both  sides,  enlarged  spleen,  hepatitis,  gastro-intestinal  catarrh, 
syphilitic  osteochondritis  at  the  epiphyses  of  the  tibiae. 


Tab.  58. 


LUh.  Ariat  F.  Reidihold,  Aiimchen,. 


4 


PLATE    59. 
Papulovesicopustular  Exanthema.    Hereditary  Syphilis. 

On  the  legs  and  on  the  soles  of  the  feet  papular  and  vesicular 
infiltration  and  vesicles,  ranging  in  size  from  a  lentil  to  a  pea, 
containing  pus  and  surrounded  by  an  inflammatory  halo. 

F.  J.,  born  June  9,  1897;  admitted  to  the  Foundling  Asylum 
June  10,  1897.  Weight  at  the  time  of  admission  8J  pounds. 
Mother  apparently  healthy. 

On  June  15th  an  eruption,  consisting  principally  of  papules, 
appeared  on  the  palms  of  the  hands  and  soles  of  the  feet.  On 
the  following  day  the  extensor  surface  of  the  lower  extremities, 
the  nates,  and  the  back  were  also  covered.  Some  vesicles  and 
pustules  are  seen  among  the  papules.    The  nose  is  not  affected. 

Later  on  symptoms  of  bilateral  lobular  pneumonia  and  gas- 
tro-intestinal  catarrh  appeared.  The  baby's  weight  gradually 
fell  to  six  pounds.     Died  June  26,  1897. 

Autopsy. — Lobular  pneumonia  in  the  lower  lobes  of  both 
lungs,  infiltration  of  the  liver,  enlarged  spleen,  gastro-intestinal 
catarrh,  no  osteochondritis. 


as 

^     i#fc 

mP^. 

^ 

PLATE   60a-c. 
Hereditary  Syphilis. 

(Parenchymatous  keratitis ;  syphilis  of  the  bones  of  the  nose ;  Hutch- 
inson's teeth.) 

K.  A.,  20  years  old,  servant ;  admitted  June  5,  1897,  to  Pro- 
fessor Bergmeister's  ward  for  diseases  of  the  eye.  The  patient 
says  his  right  eye  was  diseased  nine  years  ago.  The  disease  in 
the  left  eye  began  two  weeks  ago.  Photophobia  and  excessive 
lachrymal  secretion. 

Present  Condition. — The  entire  body,  though  of  normal 
build,  is  distinctly  puerile  for  its  age  of  twenty  years ;  the  bones, 
especially  those  of  the  extremities,  are  soft  and  greatly  enlarged 
at  the  joints;  the  genitals  are  infontile  and  the  pubic  hair  very 
scantily  developed.  The  compact,  dolichocephalous  skull  pre- 
sents a  marked  contrast  to  the  soft  bones  of  the  extremities. 
The  bridge  of  the  nose  is  sunken  and  saddle-shaped  (see  Black 
Plate  60c).  The  lips,  especially  the  upper  one,  heavy  and  hyjier- 
trophied.  Upon  inspection  of  the  nasal  cavity  the  cartilaginous 
as  well  as  the  bony  portion  of  the  vomer  is  found  to  be  eroded 
by  the  destructive  ulceration  ;  the  probe  strikes  upon  a  rough, 
bony  surface.  When  the  upper  lip  is  raised,  it  is  seen  that  the 
necrosis  has  invaded  the  upper  maxillary  bone,  a  narrow  bridge 
of  alveolar  process  being  necrotic  as  far  as  the  margin  and 
limited  in  front  by  a  remnant  of  gum  and  by  granulations. 
The  teeth  present  the  tyjte  of  congenital  syphilis  described  by 
Hutchinson  :  the  irregular  arrangement  and  chisel-shape,  with 
notches  in  the  margin. 

Ophthalmoscopic  Examination  (by  Professor  Bergmeister). 
— The  right  eye  diverges;  it  is  at  present  free  from  irritation  ;  in 
the  center  it  shows  traces  of  parenchymatous  cloudiness.  The 
pupil  retracts  promptly. 

Tlie  left  eye:  ciliary  irritation  ;  the  upper  margin  of  the  lim- 
bns  is  swollen,  the  adjacent  zone  of  the  cornea  dim  and  granu- 
lar. A  dense  parenchymatous  cloudiness  encroaches  upon  the 
cornea  from  under  the  upper  margin  of  the  cornea. 


Tab.  60. 


:m>-\>s\V'* 


LUh.Anxt  F  Reuhhald,  itiinrhen. 


Treatment. — Atropin  ;  inunctions ;  potassium  iodid. 
June  11.     C'ongei^tion  in  the  left  eye  has  disappeared ;  slight 
turbidity  in  the  upper  half  of  the  cornea.     Discharged  cured. 


Tab.  GOc. 


PLATE   61. 

Venereal  Ulcers  in  the  Foreskin  and  on  the  Head  of  the 
Penis. 

V.  E.,  26  years  old,  machinist;  admitted  Sept.  17, 1896.  This 
is  his  first  attack.  Patient  had  his  last  coitus  two  weeks  ago ; 
he  first  noticed  the  ulcers  ten  days  ago. 

On  the  left  side  of  the  inner  layer  of  the  prepuce  are  two 
large  venereal  ulcers,  surrounded  by  a  zone  of  moderate  in- 
flammation. The  edges  are  broken  down  and  the  floor  dis- 
charges freely.  Five  smaller  ulcers,  about  as  large  as  lentils, 
below  the  larger  ones,  and  one  ulcer  on  the  head  of  the  penis 
represent  the  second  generation  of  these  auto-infective  sores. 

The  ulcers  healed  upon  application  of  formalin-gelatin  and 
cauterization  with  carbolic  acid,  leaving  scai-s. 


PLATE   62. 

Contagious,  Coalescent  Venereal  Ulcers  in  the  Skin  of  the 
Penis.    Adenitis  of  the  Right  Inguinal  Glands. 

K.  J.,  29  years  old,  coachman;  admitted  Xov.  26,  1896. 
Patient  says  it  is~  his  first  venereal  attack ;  first  noticed  the 
sores  two  weeks  ago ;  last  coitus  three  weeks  ago. 

Present  Oondition. — In  the  skin  of  the  penis,  alxnit  its 
middle,  is  a  large  venereal  ulcer  formed  by  the  confluence  of 
several  smaller  ones ;  a  second  smaller  one  nearer  the  end  of 
the  penis,  separated  from  the  first  by  a  slender  bridge  of  skin. 
Both  ulcers  have  penetrated  beyond  the  skin ;  the  edges  are 
sloping  and  irregular  in  outline ;  the  secretion  of  pus  is  copiouS, 
and  the  ulcers  show  a  tendency  to  spread  by  undermining  the 
adjacent  skin.  The  surrounding  tissues  are  inflamed,  the 
lymphatics  of  the  dorsum  being  red  and  distinctly  visible.  In 
the  right  inguinal  region  there  is  a  tumor  as  large  as  a  child's 
fist,  red  in  the  center,  painful,  and  slightly  fluctuating. 

Treatment. — Airol  powder  locally.  Operation  for  the 
adenitis.    Cured. 


3^ 

to 


PLATE    (58. 

Paraphimosis  from  Venereal  Ulcer  on  the  Foreskin.  In- 
flammatory Edema.  Suppurative  Adenitis  in  Both 
Groins. 

S.  F.,  21  years  old,  glove-maker;  adniitted  Jan.  30,  1897. 
Last  coitus  seven  weeks  ago.  Patient  first  noticed  the  ulcers 
four  weeks  ago ;  the  adeniti.s,  two  weeks  ago. 

Present  Condition. — Prepuce  swollen  and  inflamed,  re- 
tracted ;  reposition  impossible.  Large,  supi:)urating  ulcers  in 
the  region  of  the  frenum ;  a  smaller  one  on  one  of  the  folds 
of  the  retracted  edematous  prepuce.  Inguinal  glands  swollen 
on  both  sides;  the  skin  over  them  inflamed,  and  beginning  to 
ulcerate  on  the  left  side.  Vesicular  eczema  of  the  pubic  region 
from  the  abuse  of  gray  ointment. 

Treatment. — Sulphate  of  copper  baths,  iodoform  powder  (for 
the  ulcers).  Operative  removal  of  the  suppurating  inguinal 
glands. 

Later  on,  the  ulcer  on  the  frenum  proved  to  be  indurated,  a 
papular  syphilide  appeared  on  the  trunk,  and  the  patient  had 
to  be  subjected  to  inunction-treatment. 


CO 
CO 


PLATE    64. 

Suppurative  Lymphangitis  of  the  Dorsum  Penis  (Bubonu- 
lus  Nisbethi),  with  Necrosis  of  the  Integument. 

N.  B.,  22  years  old,  locksmith  ;  admitted  Feb.  1,  1897.  The 
ulcers  appeared  three  weeks  ago.  Contraction  of  the  foreskin 
and  the  swelling  on  the  dorsum  penis  began  eight  days  ago. 
Last  coitus  two  months  ago. 

Present  Condition. — Preputial  sac  swollen  and  very  much 
inflamed.  A  purulent  secretion  flows  from  the  constricted 
opening.  About  the  middle  of  the  dorsum  penis  is  a  hemi- 
spherical tumor  projecting  above  the  surface,  about  as  large  as 
a  walnut.  The  exposed  surface  is  about  as  large  as  a  penny, 
and  presents  a  dark-brown  discoloration.  The  tumor  fluctu- 
ates. In  ft'ont  the  necrotic  scab  is  l)eginning  to  separate  from 
the  surrounding  inflamed  tissue.  On  pressure  thin  pus  oozes 
from  under  the  crust.  Multiple  swelling  of  the  inguinal 
glands,  especially  of  the  right  side.  After  a  few  days  the 
abscess  was  evacuated,  the  necrotic  covering  fell  off",  and  a  large 
ulcer  was  exposed,  the  upper  margin  of  which,  lying  toward  the 
pubic  region,  appeared  undermined,  so  as  to  simulate  a  fistula, 
while  the  floor  was  covered  with  a  copious  purulent  secretion. 

Cured  with  sulphate  of  copper  baths  and  iodoform  powder. 
Paraphimosis  removed  by  operation. 


Tab.  64. 


ichlwld,  Uiindieti 


PLATE    65. 
Abscess  of  the  Left  Gland  of  Bartholin. 

L.  J.,  19  years  old,  prostitute ;  admitted  March  10,  1896. 
Patient  had  no  knowledge  of  her  gonorrhea.  Pain  and  swell- 
ing began  six  days  ago. 

The  left  labium  majus  is  converted  into  a  painful  inflam- 
matory tumor  as  large  as  a  child's  fist,  red  throughout  its  whole 
extent ;  the  skin  toward  the  internal  border  thin  and  of  a  livid 
hue,  with  a  distinct  fluctuation  beneath  it.  The  tumor  has 
pushed  aside  the  right  labium  majus  and  the  left  genitocrural 
fold. 

Treatment. — Incision  of  the  abscess. 


m-- 


PLATE  66. 
Qonorrhcea  Cavernitis. 

J.  R.,  22  years  old,  confectioner.  Under  treatment  from  Feb. 
12  to  April  20,  1897.  Had  been  ill  eigbt  days  before  admit- 
tance to  the  hospital :  last  coitus  two  weeks  ago.  Acute  gonor- 
rhea. 

In  the  course  of  the  treatment  in  the  hospital  a  marked  swell- 
ing developed  on  the  under  surface  of  the  penis,  which  was  very 
painful  on  pressure. 

The  member  appears  bent,  the  concavity  looking  upward. 
When  fluctuation  appeared  to  the  right  of  the  raphg  of  the 
penis,  an  incision  was  made  and  a  moderate  amount  of  creamy 
pus  was  discharged. 

Drainage.  The  wound  healed  nicely.  Patient  was  discharged 
cured. 


CO 


OS 


PLATE  67. 
Condylomata  Acuminata. 

G.  S.,  24  years  old,  servant-girl ;  admitted  Aug.  18, 1896.  The 
patient  says  she  has  had  a  discharge  for  five  months.  The  pro- 
liferating growth  on  the  genitals  began  to  develop  two  months 
ago. 

Present  Condition. — Tlie  labia  majora,  the  perineum  as  far 
as  the  anus,  and  the  region  extending  to  the  genitocrural  folds 
are  covered  with  a  massive  tumor  composed  of  wart-like, 
nodular  papillomatous  proliferations.  The  surface  is  macerated 
in  places,  in  others  covered  witn  a  layer  of  grayish-white  hyper- 
trophied  epidermis,  and  presents  here  and  there  isolated  areas 
of  bright-red  discoloration.  When  the  labia  majora  are  held 
apart,  the  labia  minora  and  vestibule  appear  much  inflamed 
and  covered  with  isolated  and  coalescent  papillomatous  prolif- 
erations. Urethral  gonorrhea.  Purulent  discharge  from  the 
cervix  of  the  uterus. 

Treatment. — Kemoval  of  condylomata  under  chloroform 
anesthesia. 


PLATE   68. 

Condylomata  Acuminata  on  the  Coronary  Sulcus  and  on 
the  Inner  Layer  of  the  Foreskin,  which  is  Inflamed  and 
Necrotic  along  the  Left  Border. 

(The  illustration  is  a  copy  of  the  original  by  Elfinger  in  the 
collection  of  the  hospital.) 

The  left  border  of  the  foreskin  has  become  necrotic  from 
pressure  and  fallen  off;  the  necrosis  has  also  invaded  the  un- 
derlying tissue,  which  is  now  exposed.  The  right  portion  of 
the  prepuce  is  displaced  to  the  right  and  turned  back.  The 
space  within  this  expanded  preputial  sac  is  occupied  by  the 
glans  and  the  surrounding  mass  of  condylomatous  prolifera- 
tions. The  latter  are  covered  here  and  there  with  a  greenish, 
discolored  pus. 


Tab.  68. 


Lith.  Anst  F.  Reuhhold,  iluiidien. 


PLATE   69. 
Condylomata  Acuminata  at  the  Os  Uteri. 

Cz.  A.,  19  years  old,  prostitute ;  admitted  Oct.  12,  1896.  A 
raontli  ago  the  patient  was  discharged  from  a  hospital,  where 
she  had  been  treated  for  gonorrhea  and  condylomata  acuminata. 
She  says  the  condylomata  returned  four  days  (?)  ago. 

Present  Condition. — Acute  urethral  gonorrhea.  Condylo- 
mata on  the  fimbria.  Os  uteri  turned  back  and  flattened ;  on 
both  lips,  especially  close  to  the  anterior  lip,  confluent  condylo- 
mata acuminata ;  purulent  discharge  from  the  os  uteri. 

Treatment. — Removal  of  the  condylomata  with  the  curat, 
after  drawing  forward  the  uterus. 

Discharged  Dec.  22, 1896,  cured. 


Tab.  69. 


Lit/uAnsi  EReichhoUi.Munctim. 


PLATE   70. 
Subcutaneous  Hemorrhage  into  the  5kin  of  the  Penis. 

J.  R.,  39  years  old,  factory-hand.  Under  treatment  from 
May  9  to  19,  1892. 

The  patient  noticed  the  present  condition  of  the  penis  on 
May  8th,  immediately  after  sexual  intercourse.  The  woman 
with  whom  he  then  performed  the  act  of  copulation  for  the 
first  time  was,  according  to  his  statement,  not  a  virgin,  hut  was 
very  closely  built  and  he  had  to  make  a  great  effort  to  effect  an 
entrance.  The  patient  also  says  that  he  often  has  spontaneous 
attacks  of  epistaxis,  and  bleeds  very  freely  after  having  a  tooth 
pulled  or  from  the  least  cut  (hemophilia). 

Present  Condition. — Vigorous,  apparently  healthy  man. 
Nothing  abnormal  detected  in  the  internal  organs.  Genitals 
well  developed.  Penis  slightly  edematous,  especially  the  lower 
portion  of  the  prepuce.  The  skin  about  the  root  is  tense  and 
of  a  dark,  purplish  hue.  Color  of  the  glans  normal.  The  lower 
portion  of  the  prepuce  is  converted  into  a  purple,  edematous 
tumor,  somewhat  larger  than  a  walnut,  and  pendulous. 

Upon  local  application  of  cold  compresses  the  extravasa- 
tion was  absorbed,  the  skin  passing  through  the  usual  color- 
changes. 


Tab.     70. 


•f 


PLATE  71. 
Molluscum  Contagiosum  (Monilifortne  [bead-like]). 

M.  W.,  22  years  old,  washwoman;  admitted  Feb.  2,  1897. 
Has  had  a  discharge  for  two  weeks.    Gonorrhea. 

A  large  number  of  pale-red  nodules,  ranging  in  size  from  the 
head  of  a  pin  to  a  pea,  depressed  at  the  center  and  pierced  here 
and  there  by  hairs,  are  seen  disposed  in  rows  on  the  outside  of 
both  labia  majora  and  extending  in  a  straight  line  to  the  but- 
tocks. 

Treatment. — Removal  of  the  vegetations  with  the  curet. 
Discharged  Feb.  23,  cured. 


Tab      71. 


Lith.AnM  /.■  lieidiiuiUl.  A'uLcheri.. 


INTRODUCTION. 


Syphilis,  also  called  lues  venerea,  is  a  constitutional  dis- 
ease, and  is  classed  among  the  chronic  infectious  diseases. 

It  is  probable  that  syphilis,  like  tuberculosis,  glanders, 
etc.,  is  caused  by  a  micro-organism,  but  the  specific  bacillus 
has  not  as  yet  been  isolated. 

We  cannot,  in  this  short  abstract  of  the  pathology,  enter 
into  a  discussion  of  the  various  attempts  that  have  been 
made  to  explain  the  nature  of  the  syphilitic  virus,  nor 
shall  we  even  mention  the  theoretical  descriptions  and 
interpretations  of  the  pathological  product-s,  which  are 
based  on  the  mere  assumption  of  the  existence  of  a 
micro-organism  and  its  toxins. 

Syphilis  can  be  transmitted  from  an  infected  to  a  healthy 
individual  free  from  syphilis — acquired  syphilis.  It  is, 
therefore,  a  contagious  disease  which  follows  inoculation 
with  the  virus  and  infects  the  entire  organism,  giving  rise 
to  various  symptoms. 

In  addition  to  this  mode  of  infection,  syphilis  has  the 
property  of  being  transmitted  from  parent  to  offspring — 
heredikiry  syphilis. 

Depending  upon  these  two  modes  of  infection,  the  dis- 
ease presents  in  its  subsequent  course  marked  variations, 
so  that  the  two  varieties  have  for  a  long  time  been  treated 
separately.  We  shall  therefore  adliere  to  the  customary 
method  in  our  short  presentation  of  the  pathology,  and 
shall  begin  with  acquired  syphilis.  Hereditary  syphilis 
will  be  discussed  later  in  a  separate  section. 

It  shall  be  our  task  to  study  the  morbid  symptoms  pro- 
duced by  syphilis,  and  to  endeavor  in  this  way  to  acquaint 
ourselves  with  the  nature  of  the  disease. 

Acquired  syphilis  is  transferred  to  a  healthy  person 
sometimes  mediately,  but  in  the  great  majority  of  cases 


2  SYPHILIS. 

immediately.  A  focus  is  formed  at  the  point  of  inocula- 
tion, and  from  this  focus  the  virus  penetrates  into  the 
organism.  In  order  tliat  this  may  take  place,  it  is  neces- 
sary, first,  that  tlie  virus  nndtiply  at  the  point  of  entry  ; 
and,  secondly,  that  it  be  diffused  through  the  body  by 
means  of  the  lympli-  and  blood-channels. 

The  latter  process  is  gradual,  and  cannot  be  demon- 
strated by  any  known  method  of  examination ;  we  are 
therefore  limited  in  our  observations  to  the  local  manifes- 
•tations  at  the  point  of  entry  of  the  poison,  and  to  the 
symptoms  immediately  following,  until  other  morbid 
symptoms  make  their  appearance  in  other  parts  of  the 
body.  It  is  well  to  bear  in  mind,  however,  that  the  pro- 
cess of  multiplication  and  extension  of  the  virus  through 
the  organism  is  probably  a  continuous  and  uninterrupted 
one.  The  patient  soon  begins  to  complain  of  more  or  less 
subjective  disturbance,  and  visible  as  well  as  palpable 
objective  changes  in  the  integument  make  their  appear- 
ance, so  that  a  complete  general  infecti(m  can  be  definitely 
recognized  a  few  weeks  after  infection. 

For  the  sake  of  clearness  and  convenience,  rather  than 
in  accordance  with  the  actual  conditions,  the  syphilitic  phe- 
nomena are  divided  into  (1)  a  primary  stage,  comprising 
the  initial  local  symptoms  produced  by  the  infection  ;  (2) 
a  secondary  stage,  beginning  with  the  first  appearance  of 
the  general  symptoms ;  and  (3)  a  tertiary  stage,  in  which 
nodular  formations,  so-called  gummatous  neoplasms,  de- 
velop. Some  specialists  base  this  classification  on  the 
clinical  appearance  of  the  symj)toms ;  others,  on  the 
period  at  which  they  are  observed  to  occur.  As  a  mat- 
ter of  fact,  the  division  does  not  correspond  with  the 
actual  nature  and  course  of  the  disease ;  for,  although 
there  are  so-called  latent  or  intermission-periods  during 
which  the  organism  is  apparently  free  from  the  symp- 
toms of  the  following  group,  we  know  that  the  virus 
continues  to  live  and  multiply  within  the  body,  and 
sooner  or  later  gives  rise  to  renewed  symptoms.  Per- 
haps it  would  be  more  exact  to  designate  the  primary 


INTRODUCTION.  3 

and  secondary  symptoms  together  as  the  irritative  stagey 
as  Virchow  did  long  ago,  separating  them  from  the  later 
gummatous  neoplasms  and  degenerations  of  single  organs 
which  may  or  may  not  develop. 

It  is  impossible  to  foretell  in  a  given  case  how  many 
more  symptoms  will  appear  in  the  organism,  or  how 
severe  a  course  the  disease  is  destined  to  run.  No  favor- 
able prognosis  can  be  based  on  the  mildness  either  of  the 
initial  symptoms  at  the  point  of  infection  during  the  pri- 
mary period,  or  of  the  general  symptoms  in  the  skin  and 
mucous  membranes  during  the  secondary  period.  Judg- 
ing by  our  own  experience,  we  can  only  say  that  strong, 
healthy  individuals  justify  the  hope  that  they  will  easily 
get  over  the  disease,  while  patients  who  have  been  weak- 
ened by  tuberculosis,  malaria,  or  even  by  intercurrent 
diseases,  will  probably  suffer  more  under  similar  condi- 
•  tions.  It  is  therefore  important  to  be  even  more  cautious 
in  prognosis  with  such  individuals  than  in  the  case  of 
otherwise  healthy  subjects.  Very  young,  undeveloped 
individuals,  and  children  who  have  become  infected  with 
syphilis,  suffer  more  severely,  as  the  tender,  growing  or- 
ganism falls  an  easy  prey  to  the  ravages  of  the  disease. 
The  physician  is  therefore  unable  to  say  definitely  to  a 
patient  that  his  malady  will  come  to  an  end  at  such  and 
such  a  time  with  such  and  such  a  symptom.  As  a  rule, 
syphilis  terminates  with  the  irritative  stage  or  the  so- 
called  secondary  symptoms.  Unfortunately,  however,  in 
many  cases  gummatous  neoplasms  develop  in  spite  of  the 
most  careful  treatment  and  management,  and  these  neo- 
plasms are  capable  of  damaging  the  organism  more  than 
the  milder  inflammatory  and  infiltrative  processes  of  the 
secondary  period.  In  spite  of  the  efforts  of  many  skil- 
ful specialists,  no  definite  signs  have  yet  been  discovered 
which  enable  the  physician  either  to  pronounce  an  attack 
of  syphilis  definitely  ended,  or  justify  him  in  expecting 
the  occurrence  of  tertiary  symptoms.  Until  new  methods 
of  examination  are  discovered  which  shall  enable  us  to 
pronounce  a  body  free  from  syphilis,  we  shall  be  forced 


4  SYPHILIS. 

to  rely  on  certain  empirical  facts  to  determine  whether  or 
not  the  disease  is  permanently  cured.  These  facts  are  :  a 
healthy,  vigorous  condition  of  the  general  system  before 
syphilis  is  acquired;  a  certain  regularity  in  the  appear- 
ance of  the  symptoms ;  the  effect  of  appropriate  treat- 
ment; and,  finally,  freedom  from  any  symptom  of  the 
disease  for  a  number  of  years.  The  following  scheme 
will  be  found  to  hold  good  for  most  cases : 

The  interval  from  the  time  of  infection  to  the  appear- 
ance of  secondary  symptoms  is  about  eight  iveehs.  This 
period  includes  the  development  of  the  initial  induration 
— within  the  first  three  weeks — the  involvement  of  the 
neighboring  lymph-glands  and  sometimes  of  the  lym- 
phatics leading  to  them,  and  subjective  disturbances,  com- 
plained of  by  some  patients  before  the  appearance  of  the 
rash.  The  first  rash  disappears,  and  after  about  three 
months — that  is,  six  months  after  infection — a  syphilide 
usually  develops  in  some  of  the  mucous  membranes.  The 
subsequent  course  of  the  disease  is  characterized  by  the 
appearance,  at  irregular  intervals,  of  localized  rashes 
which  yield  to  appropriate  treatment.  With  the  end  of 
this  period,  which  usually  lasts  from  one  and  a  half  to 
two  years,  the  disease  itself  usually  terminates. 

An  exception  to  this  scheme  is  formed  by  the  more 
malignant  cases,  in  which  there  are  no  intervals  of  free- 
dom from  the  disease,  tertiary  and  secondary  symptoms 
occur  together,  and  nervous  disturbances  and  general 
systemic  disease  manifest  themselves  early.  These  con- 
stitute the  malignant  form^  of  syphilis.  Between  these 
two  varieties,  in  point  of  frequency,  are  those  cases  in 
which  tertiary  forms  develop  after  a  latent  interval,  dur- 
ing which  tlie  patient  is  entirely  free  from  all  symptoms. 

THE  PRIMARY  STAGE  OF  ACQUIRED  SYPHILIS. 

Conditions  of  Infection. 

Certain  conditions  are  necessary  for  the  infection  of  an 
individual  with  syphilis.     In  the  first  place,  he  must  be 


PRIMARY  SYPHILIS.  5 

free  from  the  disease ;  and,  secondly,  there  must  be  some 
loss  of  epithelium  or  epidermis — in  short,  some  sort  of 
wound — on  the  surface  of  the  body  for  the  infection  to 
take  place. 

Syphilis  in  attacking  an  organism  renders  it  immune 
against  subsequent  infection  for  a  long  time.  It  is  true, 
even  such  an  immune  individual  may  be  infected  by  an 
ulcer;  but  it  is  only  an  apparent  syphilitic  infection, 
since  the  ulcerative  process  which  results  is  always  purely 
local  and  entails  no  further  consequence  to  the  organism. 

The  abrasion,  which  is  probably  the  most  important 
condition  of  a  syphilitic  infection,  may  either  be  effected 
at  the  time  of  exposure — for  instance,  during  coitus ;  or 
it  may  have  existed  before  infection  took  place — for  in- 
stance, an  erosion  after  herpes  prseputialis  or  labialis. 
Syphilitic  infection  may,  it  is  true,  take  place  even  if  the 
tissues  are  not  injured,  but  only  if  they  are  in  a  certain 
condition  and  the  secretion  which  contains  the  syphilitic 
virus  acts  for  a  long  period  of  time,  setting  up  an  irrita- 
tion in  the  ducts  of  glands  or  in  the  delicate  mucous 
membranes  (preputial  sac,  rima  pudendi) ;  while  on  the 
other  hand,  even  very  short  contact  with  an  open  wound 
is  followed  by  infection. 

Whether  the  infection  occur  through  direct  contact 
with  a  syphilitic  body  (immediate  infection)  or  through 
some  object  polluted  with  the  secretion  of  a  syphilitic 
sore  (mediate  infection),  the  subsequent  course  of  the  dis- 
ease is  the  same. 

Channels  of  Infection. 

An  individual  in  the  acute — that  is,  the  completed,  in- 
fectious— stage  of  syphilis  is  justly  considered  a  menace 
to  his  surroundings.  The  virus  is  most  abundant  in  the 
secretions  of  syphilitic  ulcers,  but  it  is  also  present  in  the 
blood  and  lymph  during  these  stages.  It  is  not  contained 
in  the  normal  secretions  of  the  body,  as  the  saliva,  milk, 
and  seminal  fluid,  although  even  these  may  become  mixed 


6  SYPHILIS. 

with  the  virus  on  their  way  through  the  organism  or  at 
the  points  where  they  reach  tlie  surface,  the  oral  cavity, 
the  mamma,  and  in  disease  of  the  very  vascular  testicles 
which  may  not  be  demonstrable  clinically.  Persons  with 
acquired  as  "vvell  as  with  hereditary  syphilis,  as,  for  in- 
stance, children  with  syphilitic  pemphigus  and  papillo- 
mata,  are  a  source  of  danger  to  a  non-syphilitic  organism 
for  many  years.  Recent  observations  have  shown  that 
old  sores  which  scarcely  inconvenience  the  patient  may 
give  the  infection  long  afterward,  if  they  happen  to  be- 
come raw  througli  maceration  or  some  mechanical  means. 
We  may  mention  in  this  connection  old  anal  and  perianal 
infiltrations,  tongue  affections,  and  many  other  so-called 
places  of  predilection  of  the  syphilitic  products  Mhicli  will 
be  discussed  later. 

It  is  generally  held  that  the  tertiary  syphilitic  products, 
the  so-called  gummatous  neoplasms,  cannot  carry  the 
infection,  but  the  statement  must  be  taken  with  a  reser- 
vation. Thus,  cases  in  which  tertiary  coexist  with  sec- 
ondary symptoms,  and  which  therefore  belong  to  the 
group  of  tertiaiy  forms,  unquestionably  do  carry  the 
infection.  Still,  the  infective  power  of  gunmiatous  pro- 
cesses is  undeniably  weaker  than  that  of  secondary  lesions, 
the  principal  reason  probably  being  that  the  gumma  dis- 
integrates mucli  later,  after  the  infiltration  has  undergone 
a  retrogressive  metamorphosis,  so  that  nothing  is  left 
but  a  detritus  in  which  the  syphilitic  virus  has  become 
weakened  or  even  destroyed.  Another  reason  is  that  the 
gummatous  forms  are  often  localized  in  situations  from 
which  infection  is  impossible  (internal  organs),  and, 
finally,  the  patients  themselves  dread  and  avoid  contact 
with  the  gummatous  ulcers  on  account  of  the  pain  it  gives 
them.  The  secondary  lesions,  on  the  other  hand,  which 
lie  more  superficially  and  disintegrate  very  soon  after 
they  are  formed,  result  in  extensive  tissue-destruction 
with  copious  secretion  which  is  much  more  likely  to 
carry  the  infection  than  that  of  gummatous  ulcers. 

Old  ulcers  resulting  from  gummatous  wheals  and  tissue- 


PRIMARY  SYPHILIS.  7 

alterations,  like  hyperostoses  and  eburnations  in  the  bones, 
are  to  be  regarded  as  the  remains  of  old  syphilitic  prod- 
ucts in  those  situations  and  contain  no  virus. 

So  far  we  have  mentioned  only  human  syphilitic  bodies 
as  carriers  of  the  virus,  but,  in  addition,  a  great  variety 
of  objects,  such  as  spoons,  glasses,  wind-instruments,  sur- 
gical instruments,  bandages,  etc.,  are  capable  of  carrying 
the  infection  if  they  have  previously  come  in  contact 
with  syphilitic  wounds  and  some  of  the  secretion  has 
stuck  to  them.  Desiccation  of  the  syphilitic  secretion 
does  not  render  the  virus  harndess.  Very  high  temper- 
atures or  freezing,  on  the  other  hand,  so  far  as  our  pres- 
ent experience  goes,  are  ciipable  of  destroying  the  virus. 

The  First  Phenomena  that  Appear  after  Syphilitic 
Infection. 

The  first  phenomena  that  appear  after  infection  possess 
no  characteristic  features  on  which  to  base  an  opinion  as 
to  the  effectiveness  of  the  infection.  They  comprise 
wounds  which  existed  before  the  suspected  infection, 
or  of  fresh  lesions  sustained  at  the  time  of  infection, 
or  of  macerations  of  the  epithelium  or  epidermis  in 
the  region  of  the  above-mentioned  folds  or  ducts  of 
glands,  usually  about  the  genitalia.  The  patients  rarely 
consult  a  physician  at  this  period  unless  they  are  in  the 
habit  of  observing  themselves  closely  and  are  aware  that 
the  lesion  is  directly  due  to  contact  with  a  foreign  body. 
Persons  who  know  nothing  about  syphilis  or  have  been 
infected  indirectly  are  often  very  slow  to  seek  medical 
assistance,  sometimes  not  before  secondary  symptoms 
have  developed  throughout  the  entire  body.  It  follows 
from  what  we  have  said  that  the  physician  is  seldom  in  a 
position  to  say,  shortly  after  the  occurrence  of  infection, 
more  than  that  the  erosion,  or  skin-lesion,  or  ruptured 
vesicles  (as,  for  instance,  after  herpes)  have  a  more  or  less 
suspicious  look  ;  he  might  perhaps  determine  by  an  ex- 
amination of  the  individual  suspected  of  being  the  source 


8  SYPHILIS. 

of  the  infection,  whether  he  has  to  deal  with  a  syphilitic 
affection  or  not. 

It  makes  a  difference  whether  the  infection  is  due  to 
syphilitic  products  alone,  or  whether  a  purulent  secretion 
from  a  venereal  infectious  sore  was  inoculated  at  the  same 
time.  In  the  former  case  we  have  a  slowly  develop- 
ing ulcerative  process,  or  rather  a  gradual  infiltration  in 
the  affected  area ;  while  in  the  latter  case  the  acute  course 
of  the  venereal  ulcer,  its  rapid  disintegration  and  profuse 
purulent  secretion  conceal  the  signs  of  syphilitic  infec- 
tion so  effectually  that  it  is  only  after  the  ulcer  has  healed 
that  the  specific  nature  of  the  process  is  recognized.  All 
wounds  of  this  kind,  even  venereal  infectious  ulcers,  can 
be  completely  cured  by  antiseptic  treatment  and  careful 
management ;  but  it  does  not  necessarily  follow  that  the 
entire  morbid  process  is  ended.  Infiltration  often  develops 
after  scar-formation,  the  neighboring  groups  of  glands  be- 
come swollen,  constituting  a  true  initial  infection,  which 
produces  the  same  effects  on  the  organism  as  if  it  had 
originated  in  a  simple  syphilitic  ulcer. 

As  a  rule,  however,  the  small,  insignificant  abrasions 
are  gradually  converted  into  rounded  ulcers,  spotted  on 
the  surface,  which  give  but  a  scanty  secretion  and  cause 
little  discomfort  to  the  patient.  In  the  course  of  the 
second,  and  especially  the  third,  week  the  typical  infil- 
tration develops  at  the  base  and  near  the  periphery ;  it 
takes  on  a  spherical  nodular  form,  is  hard  to  the  touch, 
and  represents  the  so-called  induration  or  sclerosis 
(PI.  1).  The  degree  of  infiltration  depends  on  the  local 
nature  of  the  tissue  in  which  the  infection  takes  place. 
Thus,  for  instance,  we  frequently  see  on  the  glans  penis 
and  at  the  vaginal  orifice  flat  infiltrations,  eroded  on  the 
surface  (erosio  superficialis  sclerotica).  On  the  surface  of 
the  body,  especially  where  the  skin  is  loosely  attached 
to  the  underlying  tissue,  we  find  nodular,  hard  infiltra- 
tions, elevated  above  their  surroundings,  which  attain 
their  greatest  extent  in  parts  covered  with  hair  and 
rich  in  glands  (Plates  2  to  11).     We  have  seen  such  an 


PRIMARY  SYPHILIS.  9 

induration  about  the  size  of  a  half  dollar  on  the  chin, 
which  closely  resembled  a  neoplasm,  and  it  is  not  so  very 
long  ago  that  such  syphilitic  indurations  on  the  lips,  breast, 
etc.,  were  mistaken  for  epitheliomata.  If  such  initial  le- 
sions are  situated  in  parts  much  subject  to  traction,  as,  for 
instance,  at  the  corners  of  the  mouth,  at  the  junction  of 
palate  and  tongue,  in  the  tonsils,  the  anus,  etc.,  they  take 
the  form  of  ulcerative  fissures,  and  often  complicate  the 
diagnosis  of  induration  by  the  rapid  disintegration  of  the 
infiltrate.  Syphilitic  tissue  in  general,  particularly  an  ex- 
tensive induration,  rapidly  undergoes  gangrenous  decay 
from  pressure  or  traction,  so  that  the  induration  disap- 
pears and  a  large  ulcer  is  formed.  In  the  same  way 
inappropriate  treatment,  especially  useless,  unnecessary 
cauterization,  may  cause  the  infiltrate  to  break  down, 
and  lead  to  the  formation  of  a  large  ulcerated  surface. 
From  the  point  of  infection  the  syphilitic  virus  pene- 
trates into  the  body  through  the  lymph-  and  blood-chan- 
nels. The  lymph-capillaries  especially  take  up  the  greater 
part  of  the  tissue-juices  flowing  back  from  the  periphery, 
and,  uniting  to  form  larger  vessels,  carry  it  to  the  nearest 
glands.  The  returning  blood-vessels,  the  veins,  also  no 
doubt  take  up  the  virus  from  the  induration  and  carry  it 
to  the  rest  of  the  body ;  but  in  the  case  of  the  lymphatics 
we  have  clinical  and  histological  proof.  Whoever  has  had 
the  opportunity  to  observe  a  large  number  of  cases  v/ill 
remember  many  in  which  the  tissue  immediately  sur- 
rounding the  induration  was  swollen  and  almost  as  hard 
and  unyielding  as  the  induration  itself,  was  edematous  to 
the  touch,  and  sent  out  hard,  tough  cords  to  some  distance, 
easily  traceable  to  the  glands  of  the  region, — for  instance, 
along  the  dorsum  of  the  penis  when  the  induration  was 
seated  in  the  prepuce.  These  changes  begin  with  a  cap- 
illary or  cord- like  lymphangitis  with  nodular  SAvellings. 
If  the  lymphangitis  is  very  superficial,  or  the  nodular 
swellings  are  extensive,  superficial  excoriations  or  even 
complete  decay  not  infrequently  result.  Such  nodular 
ulcers  may  appear  like  so  many  separate  points  of  infec- 


10  SYPHILIS. 

tion ;  sometimes  a  lymphangitis  of  this  character,  follow- 
ing upon  the  initial  lesion,  may  give  rise  to  extensive 
swelling  and  result  in  a  high  degree  of  deformity  involv- 
ing the  entire  genitalia,  a  very  obstinate  condition  which 
has  been  designated  indurative  edema  (^Plates  5, 
12).  It  usually  yields  to  general  treatment  and  disappears 
entirely  upon  the  advent  of  secondary  symptoms.  This 
variety  of  indurative  edema  is  to  be  distinguished  from 
acute  inflammatory  edema,  an  acute  process  which  may 
accompany  any  septic  or  ulcerative  wound,  and  occasion- 
ally leads  to  abscess-formation  in  the  course  of  the  lym- 
phatics, as  in  venereal  ulcer  (bubonulus  Nisbethii). 

Swelling  of  Lymph=glands. 

A  constant  phenomenon  in  the  subsequent  course  of  a 
syphilitic  infection  is  swelling  of  the  lymph-glands  near- 
est the  point  of  infection,  indurations  of  the  genitalia  of 
the  inguinal  glands,  induration  of  the  mouth  and  lips 
(Plates  9,  10),  of  the  submaxillary  and  submental 
glands,  etc.  It  is  the  outward  expression  of  a  widespread 
round-celled  infiltration  which  now  attacks  the  lymph- 
glands  themselves,  after  running  its  course  in  the  initial 
induration  and  the  lymphatics  leading  from  it.  The 
swelling  is  usually  moderate  in  simple  syphilitic  ulcers 
and  causes  little  discomfort  to  the  patient.  But  in  degen- 
erating ulcers  and  in  cases  of  mixed  infection  the  glandu- 
lar irritation  is  much  more  intense.  The  swelling  is  often 
so  great  as  to  form  tumors  as  large  as  the  fist,  which  break 
down  at  various  points  and  present  a  so-called  strumous 
adenitis.  It  often  occurs  in  individuals  weakened  by 
scrofula,  tuberculosis,  etc.,  even  when  the  peripheral  irri- 
tation is  comparatively  slight. 

Phimosis  and  Paraphimosis. 

There  is  one  very  frequent  complication  of  the  initial 
form  in  the  male  organ,  especially  in  the  prepuce  and 
neck.     In  such  cases  the  prepuce,  owing  to  the  infiltra- 


SECONDARY  SYPHILIS.  11 

tion  surrounding  the  induration,  becomes  completely  im- 
movable and  rigidly  adherent  to  the  glans  (PJ.  12).  Such 
phimoses  develoj)  even  when  the  fore-skin  was  origi- 
nally quite  loose,  and  are  sure  to  occur  if  even  a  slight 
constriction  was  present.  The  constant  pressure  leads  to 
resolution  and  not  rarely  to  gangrene  of  the  indurated 
area.  If  the  gangrene  is  not  checked,  the  prepuce  be- 
comes perforated  and  the  glans  may  slip  through  the 
Opening  thus  formed.  We  have  seen  cases  in  which  the 
gangrene  had  completely  destroyed  the  prepuce  and  had 
even  spread  to  the  skin  of  the  penis  and  of  the  scrotum, 
so  that  the  corpora  cavernosa  as  well  as  the  testicle  and  its 
supplying  vessels  were  exposed.  If  such  an  infiltrated 
prepuce,  before  it  becomes  quite  immovable,  is  forcibly 
pushed  back,  reposition  is  rarely  possible  (paraphimo- 
sis). The  prejjuce  becomes  edematous  ;  and  the  neck  of 
the  penis  undergoes  necrosis.  The  circulation  in  the  glans 
and  in  the  retracted  prepuce  is  impeded  and,  if  the  con- 
dition persists  for  some  time,  the  edema  is  replaced  by  a 
permanent  inflammatory  infiltration,  reposition  of  the  pre- 
puce is  no  longer  possible,  and  a  permanent  deformity  of 
the  penis  results. 

THE  SECONDARY   STAGE  OF  SYPHILIS. 
Prodromal   Symptoms   during  the    Eruptive   Period. 

While  the  local  symptoms  are  developing  with  more  or 
less  intensity,  the  virus  penetrates  into  the  system  from  the 
point  of  infection  by  way  of  the  lymph-  and  blood-chan- 
nels, without  other  changes  than  those  we  have  mentioned 
manifesting  themselves  for  some  time,  usually  until  the 
fifty-seventh  day  after  infection.  The  cases  are,  however, 
not  uniform  by  any  means.  In  a  large  proportion  (])er- 
haps  more  than  half)  the  presence  of  grave  systemic  dis- 
ease betrays  itself  by  certain  subjective  symjjtoms  during 
the  period  when  the  disease  is  spreading  through  the 
body,  without  manifesting  itself  by  any  marked  external 
changes.     The  patients  complain  of  lassitude  and  depres- 


12  SYPHILIS. 

sion  many  days  before  the  breaking  out  of  the  exanthema; 
they  are  pale,  with  black  rings  under  the  eyes — in  short, 
they  have  a  distinct  morbid  appearance.  At  the  same 
time  they  complain  of  pains  localized  in  different  portions 
of  the  body  :  headache,  intercostal  neuralgia,  pain  on  press- 
ure in  the  sternum,  especially  near  the  points  of  union 
with  the  costal  cartilages,  without  any  demonstrable  swell- 
ing, tenderness  in  single  joints  or  groups  of  muscles,  etc. 
The  latter  are  sometimes  called  rheumatoid  pains  and  are 
often  mistaken  for  incipient  rheumatism.  The  patients 
also  exhibit  a  certain  unrest  and  abnormal  excitability, 
which  in  some  persons  merely  take  the  form  of  irritability 
and  moodiness,  but  in  others,  who  had  before  been  quite 
well,  bring  on  violent  palpitations  of  the  heart  at  the 
least  exertion,  such  as  going  up-stairs.  Such  patients  also 
suffer  from  insomnia,  either  without  any  direct  cause,  or 
in  consequence  of  the  pains  which  usually  increase  toward 
nightfall,  so  that  the  general  health  becomes  impaired. 
The  symptoms  we  have  referred  to  may  be  present  singly, 
or  several  at  the  same  time.  A  few  patients  have  a  slight 
rise  in  temperature  of  from  0.5°  to  1",  toward  evening, 
but  this  is  the  exception  (syphilitic  fever). 

After  a  variable  interval,  usually  from  a  week  to  ten 
days,  these  symptoms  gradually  disappear,  often  without 
any  treatment,  and  the  exanthema  develops,  which  brings 
us  to  the  so-called  secondary  period. 

It  will  be  well  to  mention  now,  before  taking  up  the 
other  morbid  products  of  the  secondary  period  of  syph- 
ilis, that  as  a  rule  there  is  a  gradual  swelling  of  the  pal- 
pable glands  (general  syphilitic  glandular  svelling)  in  the 
most  varied  regions  of  the  body,  usually  observed  about 
the  same  time  as  the  first  appearance  of  the  general 
symptoms.  The  supraclavicular,  cervical,  nuchal,  retro- 
auricular,  the  axillary,  cubital,  and  other  glands  are 
found,  either  all  or  only  in  groups,  to  be  somewhat 
increased  in  size  and  considerably  indurated.  The  con- 
dition is  most  marked  in  scrofulous  and  anemic  or  other- 
wise debilitated  subjects. 


SECONDARY  SYPHILIS.  13 

Even  in  later  stages  of  the  disease  the  lymphatic  sys- 
tem plays  an  important  part,  both  independently  and  in 
connection  with  ulcerative  processes  in  the  skin.  In  the 
secondary  period  we  also  have  enlargement  of  the  spleen, 
which,  however,  is  difficult  to  detect  and  does  not  occur 
in  every  case.  We  shall  return  to  these  pathological 
alterations  in  a  later  section. 


The  Syphilitic  Exanthemata. 

The  syphilitic  exanthemata  of  the  secondary  period  are 
divided,  according  to  their  histological  appearance  and 
clinical  course,  into  three  groups — macular,  papular,  and 
pustular.  In  addition,  so-called  squamous  forms  occur 
in  very  rare  cases  as  a  result  of  the  papular  exanthemata ; 
they  are  called  squamous  because  they  early  show  a  ten- 
dency to  superficial  desquamation  (PI.  20). 

The  syphilitic  exanthemata  exhibit  certain  general 
chaj-acteristics  regularly  seen  in  all  forms.  The  rash  is 
usually  distributed  symmetrically  over  both  sides  of  the 
body  and  follows  the  fibers  of  the  skin,  especially  in 
copious  eruptions.  Thus,  for  instance,  on  the  back  the 
eruption  is  disposed  in  parallel  rows  running  obliquely 
downward  on  both  sides  (PI.  16).  Again,  all  syphilitic 
exanthemata,  whether  they  appear  singly  or  in  groups  of 
greater  or  less  extent,  as  in  the  advanced  stages,  have  a 
round  or  el]ii)tieal  form  (PI.  21).  This  property,  which 
is  also  found  in  other  forms  of  dermatitis,  probably  de- 
pends on  the  distribution  of  blood-vessels  in  the  skin. 
Lastly,  it  must  be  borne  in  mind  that  the  eruption  is 
only  exceptionally  uniform,  in  by  far  the  greater  number 
of  cases  it  is  polymorphous  (PI.  16).  We  observe  either 
a  direct  transition  of  single  eruptions  from  one  form  to 
another  (for  instance,  from  the  macular  to  the  papular)  or 
one  variety  developing  within  another — for  instance,  pap- 
ular forms  in  a  group  of  macular  eruptions,  papular  in  a 
pustular  group,  with  varying  characteristics  (PI.  18). 

The  Macular  Syphilide. — We  distinguish  two  forms 


14  SYPHILIS. 

of  macular  syphilides,  syphUitie  roseola  and  the  large 
macular  syphilide. 

Roseola,  the  true  representative  of  the  hypercniic  stage, 
chiefly  affects  the  trunk  ;  the  macules  are  brownish-red  in 
color  and  about  as  large  as  a  lentil  or  a  pea ;  they  are  not 
as  a  rule  raised  above  the  level  of  the  skin,  disappear  on 
pressure,  and  may  vanish  completely,  without  leaving  a 
trace,  in  a  few  days  (three  to  twelve).  As  subjective 
symptoms  are  entirely  wanting,  this  form  of  syphilitic 
eruption  almost  always  escapes  the  patient's  notice  (PI. 
13). 

The  large  macular  syphilide  occurs  later  than  roseola, 
often  in  combination  with  papular  forms,  in  the  genitalia, 
on  the  anus,  in  the  mouth,  etc.  In  the  lower  part  of  the 
body  the  color  is  livid,  in  the  upper  it  is  of  a  distinctly 
coppery  hue.  The  individual  lesions,  which  on  account 
of  their  size  are  called  maculae  majores  to  distinguish 
them  from  those  of  roseola,  called  simply  macular,  have 
received  various  names  according  to  their  shape  and  dis- 
tribution— Maculae  majores  figuratae.  Maculae  majores  gy- 
ratae,  Maculae  majores  annulares,  etc.  Their  formation 
depends  either  on  the  coalescence  of  several  adjacent  pus- 
tules or  on  the  disappearance  of  the  redness  in  the  center 
and  increased  redness  in  the  periphery  of  single  pustules, 
causing  these  rings  to  appear  more  distinctly. 

Most  large  forms  of  syphilide  are  slightly  raised  above 
the  level  of  the  skin,  and  hence  resemble  various  forms 
of  polymorphous  exudative  erythema.  They  can  easily 
be  distinguished  from  tlie  latter,  however,  by  their  longer 
duration,  the  entire  absence  of  subjective  symptoms,  and 
by  other  accompanying  symptoms. 

The  large  form  of  syphilide  is  not  a  mere  hyperemia  of 
the  skin,  as  Biesiadecki  has  sho\vn,  but  depends  on  round- 
celled  infiltration  about  the  blood-vessels  in  the  affected 
area ;  it  is  therefore  the  first  indication  of  the  infiltrations 
that  are  characteristic  of  the  papular  stage. 

As  has  been  stated,  roseola  disappears  without  leaving 
any  appreciable  changes  in  the  skin.     In  the  large  form, 


SECONDARY  SYPHILIS.  15 

on  the  otlier  hand,  Ave  observe  in  rare  instances  a  slight, 
barely  noticeable  desquamation  of  the  epidermis  in  the 
affected  areas  after  the  disappearance  of  the  eruption. 
More  frequently  the  pigmentation  disappears,  so  that  the 
affected  parts  appear  white  and  lead  to  the  formation  of 
cutaneous  leuhoplasia  (Plates  14,  15,  16). 

The  Papular  Syphilide. — The  commonest  of  the 
syphilitic  eruptions  of  the  skin,  the  so-called  syphilides, 
is  the  papular  form.  It  is  often  the  first  exanthema  to 
appear  after  general  infection  of  the  organism,  and  runs 
its  course  either  alone  or  combined  with  the  macular  or 
the  pustular  form.  The  base  of  the  papule  originally 
consists  of  a  round-celled  infiltration  in  the  papillary 
layer  of  the  skin,  the  size  and  shape  of  the  papules 
depending  on  the  extent  and  bulk  of  the  proliferated 
tissue.  In  general  appearance  it  is  the  most  variable 
form  of  syphilide.  We  may  have  nodules  ranging  in 
size  from  a  millet-seed  to  a  bean,  or  more  flattened  pap- 
ules, sometimes  as  large  as  a  five-cent  piece,  presenting 
slightly  raised  edges  and  a  somewhat  depressed  center. 
In  recent  cases  of  syphilis  the  papules  are  scattered  over 
the  entire  integument,  while  in  cases  of  longer  standing 
they  appear  localized  in  the  genitalia,  the  anus,  the  palmar 
surfaces,  the  mucous  membrane  of  the  oral  cavity,  etc. 
An  opinion  as  to  the  gravity  of  a  particular  case  may  be 
formed  from  the  shape  and  size  of  the  individual  papules. 

The  lenticular  syphilide  appears  in  collections  of  red 
nodules  on  the  trunk  and  on  the  extremities.  After  a 
relatively  short  duration — eight  to  fourteen  days — the 
individual  nodules  begin  to  show  a  dirty  white  discolora- 
tion and  desquamate.  This  form  of  papular  syphilide 
usually  leaves  no  permanent  marks  (PI.  17). 

The  smaller,  so-called  lichenoid  syphilide  usually  attacks 
scrofulous  or  tuberculous  individuals.  It  is  almost  never 
distributed  evenly  over  the  surface  of  the  body,  but  occurs 
in  groups  of  ten  to  twenty  nodules.  The  individual  pap- 
ules rarely  show  much  hyperemia  on  their  first  appear- 
ance, and  soon  undergo  a  yellowish  discoloration,  suggest- 


16  SYPHILIS. 

ing  the  picture  of  scrofulous  lichen,  especially  if  the 
eruption  is  copious.  This  form  often  persists  a  long 
time  in  spite  of  the  most  energetic  treatment,  and  Avhen 
it  finally  does  yield,  the  nodules  at  first  desquamate  on 
the  surface,  but  in  the  end  the  scabs  come  away  bodily 
and  leave  minute  punctiform  depressions  in  the  skin 
(Plates  19,  20). 

Another  form  is  the  flat,  glistening,  papular  syphilide 
(papidce  nitentes),  which  is  usually  observed  on  the  nose, 
in  the  nasolabial  furrows,  on  the  forehead — in  short,  on 
the  face  generally.  The  individual  papules  exhibit  a 
pale-red,  shining  surface,  moderately  raised,  sharp  edges, 
and  a  slightly  depressed  center.  With  proper  treatment 
the  papules  desquamate  and  disappear,  usually  without 
leaving  any  visible  alterations  in  the  skin  (PI.  25). 

Orbicular  papules  (PI.  21)  constitute  a  late  form  which 
frequently  occurs  in  relapse  and  affects  the  seats  of  pre- 
dilection (genitalia,  anal  region,  etc.),  or  in  connection 
with  diseased  organs  (eye).  The  individual  papules 
appear  in  the  form  of  larger  or  smaller  rings,  according 
to  the  duration,  exhibiting  a  slight  depression  with  brown- 
ish pigmentation  in  the  center,  and  separated  by  raised 
edges  from  the  normal  epidermis.  The  exudation  at  the 
borders  of  the  papules  is  sometimes  so  profuse  that  the 
epidermis  is  loosened  and  forms  a  dry  crust  about  the 
papule.  As  the  sores  begin  to  heal,  the  edges  gradually 
flatten  out  and  the  center  slowly  regains  its  normal  color 
by  desquamation. 

In  conclusion,  we  may  mention  the  grouped  variety  of 
papular  ssrphilides  (tubercula  cutanea  [Ricord],  papulse 
cumulis  coacervatae).  This  nodular  form  of  syphilide 
occurs  only  in  the  later  stages  of  syphilis,  often  associated 
with  bone-  and  joint-affections,  occasionally  with  true 
serpiginous  ulcers.  The  individual  groups  vary  in  size 
from  a  half  dollar  to  the  palm  of  the  hand,  and  are  made 
up  of  infiltrates  as  large  as  a  pea,  occupying  the  entire 
thickness  of  the  skin  and  covered  either  with  layers  of 
dead  epidermis  or  with  a  thick,  dry  crust.     The  skin 


SECONDARY  SYPHILIS.  17 

between  these  raised  nodules  exhibits  a  dark-red  or  brown 
pigmenttition.  This  form  of  papular  syphilide  may  per- 
sist for  many  months.  It  finally  disappears  either  by 
absorption  and  superficial  desquamation,  resulting  merely 
in  a  shallow  depression  in  the  epidermis,  or  by  ulceration 
and  superficial  crust-formation,  leading  to  deep  scar-for- 
mation and  permanent  alteration  of  the  affected  area 
(Plates  22,  23).  This  late  form  of  nodular  syphilide 
resembles  the  destructive  forms  of  the  gummatous  stage 
in  its  mode  of  healing,  and  is  sometimes  classed  as  a 
superficial  cutaneous  gumma. 

The  Pustular  Syphilide. — The  pustular  syphilides 
cause  vastly  more  discomfort  to  the  patient  than  do  the 
macular  and  pa])ular  forms.  They  rarely  occur  as  an 
initial  eruption,  l)eing  preceded  by  macular  and  papular 
forms  in  the  great  majority  of  cases.  Papular  and  pus- 
tular rashes  sometimes  exist  together.  There  are  cases, 
however,  where  the  pustular  syphilide  constitutes  the 
initial  eruption,  and  these  cases  deserve  special  attention 
because  they  represent  a  more  acute  and  rapid  form  of 
syphilis,  in  the  prognosis  of  which  the  physician  should 
be  exceedingly  cautious. 

An  eruption  of  pustular  syphilide  is  usually  preceded 
by  grave  general  symptoms.  There  are  evening  rises  in 
temperature ;  the  patient  looks  pale  and  weak,  he  ex- 
hibits a  strange  restlessness,  and  often  complains  of  las- 
situde, headache,  and  pains  in  the  limbs.  In  this  stiige 
of  syphilis  we  often  meet  with  disturbances  which  point 
to  disease  of  internal  organs — for  instance,  icterus,  al- 
bumin in  the  ui-ine,  etc.  (PI.  18). 

We  distinguish  several  forms  of  pustular  syphilide. 

Very  often  the  eruption  is  characterized  during  its 
dev^elopment  by  copious  seropurulent  exudations,  the 
epidermis  is  loosened,  and  the  pustules  take  on  the  ap- 
pearance of  vesicles — the  so-called  vesiculous  syphilide 
(variola  syphilitica).  Later,  the  epidermis,  together  with 
the  contents  of  the  vesicle,  forms  a  dry  scab  svhich  is  cast 
2 


18  SYPHILIS. 

off  and  exposes  the  papillary  layer.  In  most  cases  a 
newly  formed  epidermis  is  seen  under  the  scab. 

To  this  variety  belongs  the  pustula  minor,  also  called 
acneiform  syphilide ;  the  individual  nodules  resemble  a 
papule  witli  a  purulent  vesicle  in  the  center.  The  affected 
areas  usually  correspond  to  the  ojjenings  of  the  hair-fol- 
licles and  ducts  of  sebaceous  glands.  The  vesicle  is  soon 
converted  into  a  brown  scab  which  covers  the  dome  of 
the  pustule  (PI.  27). 

The  most  important  representative  of  the  group  is  the 
pustula  major.  This  pustular  syphilide  occurs  either  alone 
or  in  combination  with  the  acneiform  variety,  and  is 
characterized  by  its  size,  rapid  disintegration,  and  a  ten- 
dency on  the  part  of  the  individual  pustules  to  coalesce. 
The  patient  complains  of  burning  pain,  which  is  produced 
by  the  syphilide  itself  and  becomes  greatly  aggravated 
when  the  clothing  or  bed-linen  sticks  to  tiie  freely  secret- 
ing pustules.  The  crusts  are  frequently  torn  off  and 
replaced  by  deep  ulcers  with  a  dirty  white  floor,  Avhich 
gradually  destroy  the  entire  infiltrated  ])apillary  stratum. 

If  the  pustule  spreads  out  superficially  instead  of 
attacking  the  deeper  tissues,  we  get  the  so-called  ecthyma- 
pustule  (Plates  28,  29). 

Sometimes  the  crusts  which  cover  the  })ustules  grow 
upward.  The  exudation  proceeds  slowly  and  gradually  ; 
the  secretion  dries  as  fast  as  it  is  produced ;  the  scab  in- 
creases in  thickness,  and,  as  it  extends  peripherally  at  the 
same  time  by  the  melting  of  the  tissues,  new  scabs  are 
constantly  added,  and  a  formation  resembling  oyster- 
shells  is  produced,  to  Avhich  the  term  syphilitic  rupia  is 
applied  (Plates  44,  45,  49). 

The  subsequent  course  is  the  same  in  all  forms  of  pus- 
tules— they  heal  by  cicatrization.  The  scars  frequently 
exhibit  hyperemia  and  infiltration  for  some  time.  At  last 
the  hyperemia  disappears,  and  the  scar  atrophies  and 
becomes  loose,  white,  and  glistening,  with  an  encircling 
zone  of  brown  pigmentation.     The  alteration  is  perma- 


SECONDARY  SYPHILIS.  19 

nent  and  especially  noticeable  on  parts  of  the  body  covered 
with  hair,  if  the  roots  of  the  hairs  have  been  destroyed. 

In  conclusion,  we  would  mention  a  phenomenon  which 
rarely  accompanies  pustular  syphilides.  The  individual 
pustules  are  surrounded  by  an  irregular,  bright-red  zone 
several  millimeters  in  thickness  and  resembling  the  ery- 
thema of  erysipelas.  Whether  this  is  caused  by  the 
breaking  down  of  the  tissue  alone  or  by  the  generation 
of  toxins,  Ave  shall  have  to  leave  undetermined.  One 
point  should  be  emphasized  :  whenever  we  have  observed 
this  phenomenon  the  patient  was  much  reduced  and  pre- 
sented the  appearance  which  is  commonly  seen  in  grave 
febrile  diseases. 

Syphilides  with  Cutaneous  Hemorrhages. 

Hemorrhagic  syphilides  are  divided  into  two  classes. 
The  first  class  includes  cases  in  which  syphilis  is  com- 
plicated with  another  disease — for  instance,  hemophilia, 
scorbutus.  Here  the  hemorrhage  is  a  symptom  of  the 
complication,  showing  itself  in  the  blood-vessels  already 
suffering  from  the  effects  of  syphilis. 

The  cases  forming  the  second  class  are  less  numerous. 
In  these  the  formation  of  papular  or  pustular  exanthe- 
mata is  accompanied  by  hemorrhages  in  the  affected  areas 
from  the  start,  and  without  the  coexistence  of  other  dis- 
ease, so  that  the  hemorrhages  must  be  regarded  as  the 
expression  of  disease  of  the  vessels  due  to  syphilis  as 
such.  The  blood  should  be  examined  to  determine 
whether  the  hemorrhages  might  not  be  in  part  due  to 
grave  blood  disease. 

The  fact  that  the  occurrence  of  such  forms  always 
points  to  grave  disease  of  the  general  organism  must  not 
be  overlooked  in  the  prognosis,  whether  w^e  have  to  deal 
with  a  grave  complication  of  syphilis  or  with  a  particu- 
larly malignant  form  of  the  disease  itself. 

In  the  first  series  of  cases  the  complicating  affection 
must,  of  course,  receive  suitable  treatment,  just  as  in  the 


20  SYPHILIS. 

second  class  the  ulcers  which  almost  always  appear  must 
be  treated  by  suitable  local  measures  in  addition  to  the 
general  treatment. 

We  shall  discuss  this  question  more  in  detail  when  we 
come  to  speak  of  treatment. 

Abnormal  CoIor=changes. 

In  most  syphilides  there  is  a  shifting  of  the  pigmenta- 
tion ;  that  is  to  say,  the  pigment  disappears  in  the  sore 
itself  and  becomes  increased  around  its  periphery.  This 
is  particularly  the  case  in  parts  naturally  rich  in  pigment, 
as  the  na})e  of  the  neck  and  the  genital  region.  Occa- 
sionally the  entire  surface  of  the  body  is  thickly  covered 
with  pale,  non-pigmented  circular  or  oval  spots.  If  they 
come  under  observation  early  enough,  the  center  is  seen  to 
be  reddish  and  the  periphery  white,  while  the  immediate 
surroundings  are  darkly  pigmented.  Later  the  entire  area 
becomes  white  and  appears  the  more  distinctly  for  the 
darker  pigmentation  of  the  surrounding  parts.  This  so- 
called  syphilitic  leukoplasia  (Plates  14,  15,  16)  is  a 
more  valuable  sign  than  any  other,  as  it  may  represent 
the  remains  of  a  cutaneous  syphilide  of  very  long  stand- 
ing, and  forms  a  diagnostic  point  of  the  highest  importance 
in  doubtful  cases  of  diseased  organs,  such  as  retinitis  or 
endarteritis. 

Many  syphilides,  especially  such  as  are  accompanied  by 
great  hyperemia,  possess  a  directly  opposite  property  of 
depositing  large  masses  of  pigmentation,  which,  if  the 
eruption  continues  for  a  long  time,  leave  dark-brown 
spots  usually  on  the  dependent  portions  of  the  body, 
persisting  long  after  the  disappearance  of  all  other 
symptoms. 

Finally,  we  may  mention  the  pigment-destruction  which 
sometimes  results  from  the  disintegration  of  pustular  syph- 
ilides, destroying  the  papillary  layer  and  persisting  for  life 
as  whitish,  thin,  atrophic  scars  (PI.  24). 


SECONDARY  SYPHILIS.  21 

Diseases  of  the  Hairy  5calp. 

During  the  secondary  period  of  syphilis  a  variety  of 
seborrhea  of  the  scalp  often  develops,  dilFering  in  many 
essentials  from  ordinary  seborrhea.  Instead  of  increased 
secretion,  with  desquamation  of  the  epidermis,  there  is 
diffuse  infiltration  of  the  papillary  layer  and  of  the  hair- 
follicles.  The  epidermis  comes  off  in  scales ;  the  hair 
loses  its  color  and  gloss,  and  is  easily  pulled  out,  or  even 
comes  out  of  its  own  accord.  The  resulting  baldness  is 
usually  fairly  uniform  (diffuse  alopecia).  Sometimes  the 
disease  presents  the  type  of  a  papular  syphilide,  the  hair 
is  massed  in  thick  bunches,  and  the  loss  of  hair  is  confined 
to  sharply  defined  areas  about  as  large  as  a  bean  (areolar 
alopecia).  The  hair  may  be  restored  in  both  diffuse  and 
areolar  syphilitic  alopecia.  Unless  the  condition  has  lasted 
too  long,  lanugo  hairs  grow  in  three  or  four  months,  and 
are  later  replaced  by  strong,  healthy  hairs  (PI.  26a,  black 
and  colored). 

The  loss  of  hair  is,  of  course,  most  marked  in  the 
scalp,  but  it  is  to  be  remembered  that  analogous  pro- 
cesses may  also  affect  the  eyebrows,  eyelids,  and  more 
rarely  the  axillse  and  pudenda. 

Pustular  syphilide  is  a  more  common  affection  of  the 
scalp  than  the  above-mentioned  diseases.  Infiltration 
appears  around  the  hair-follicles  or  attacks  the  roots 
themselves,  so  that  while  the  hairs  are  still  held  fast  on 
the  surface  by  the  incrustation,  they  die  and  become 
loosened  Avithin  the  scalp  itself.  The  hair  loses  its  gloss 
and  soon  falls  out  in  large  bunches,  bringing  the  scabs 
with  it.  Occasionally  a  pustular  syphilide  in  the  scalp 
takes  on  a  peculiar  appearance.  Either  by  extension  of 
a  single  sore,  or  by  the  coalescence  of  several,  the  pus- 
tules attain  the  size  of  a  quarter  or  a  half  dollar.  The 
base  proliferate5^  and  forms  a  raulbei"ry-shaped  tumor 
which  may  attain  the  size  of  a  pigeon's  egg  (frambesia 
syphilitica),  and  the  surface  is  covered  with  a  dirty  brown 
scab.    The  proliferated  tissues  bleed  at  the  slightest  touch 


22  SYPHILIS. 

and  cause  the  patient  much  pain  ;  they  are  very  refractory 
to  treatment  (Phites  44,  45).  Scars  form  after  the  pus- 
tules heal,  and  bald  spots  remain  corresponding  in  extent 
to  the  areas  destroyed  by  the  process. 

Diseases  affecting  the  Palms  of  the  Hands,  the  Soles 
of  the  Feet,  the  Fingers,  and  the  Toes. 

Psoriasis  syphilitica  palmaris  et  plantaris  is 

the  commonest  form  of  syphilitic  disease  in  the  palms 
of  the  hands  and  the  soles  of  the  feet.  It  is  a  papular 
syphilide,  which,  however,  appears  much  later  than  the 
exanthemata  on  other  parts  of  the  integument  and  pre- 
sents some  essential  differences  in  its  course.  As  the 
epidermis  under  which  the  papules  form  is  very  thick, 
it  is  often  four  months  after  the  infection  before  they 
appear  on  the  surface — long  enough  for  the  entire  course 
of  a  papular  form  on  the  rest  of  the  integument.  In  some 
cases  psoriasis  palmaris  et  plantjiris  appears  much  later,, 
even  several  years  after  infection,  the  patient  meanwhile 
being  entirely  free  from  any  morbid  symptoms.  Lastly, 
the  disease  in  many  cases  offers  an  obstinate  resistance  to 
every  kind  of  treatment  and  persists  after  gummatous 
processes  and  disease  in  individual  organs  have  already 
put  in  their  appearance. 

The  papules  themselves  consist  of  small  nodules  vary- 
ing in  size  from  the  head  of  a  pin  to  a  pea,  and  covered 
with  a  tough,  horny  epidermis.  Often  the  patients  do 
not  become  aware  of  them  until  they  invade  the  region 
of  the  phalanges,  and  thus  produce  pain  either  by  direct 
pressure  or  when  the  patient  grasps  any  hard  substance. 
Sometimes  they  appear  in  the  form  of  flat,  livid  spots 
with  horny,  dirty  yellow  epidermis  in  the  center ;  the 
skin  finally  cracks  and  comes  off  in  scales.  In  rare  cases 
the  papules  attain  a  large  size  ;  more  frequently  a  number 
of  them  are  crowded  closely  together,  or  even  coalesce. 
The  skin  presents  the  ap]>earance  of  infiltration,  the 
horny  epidermis  cracks,  and  in  a  short  time,  especially 


SECONDARY  SYPHILIS.  23 

if  tlie  skin  is  hard  and  thick,  painful  fissures  develop  at 
the  flexures  which  seriously  interfere  with  the  use  of 
the  hands  and  feet,  or  even  render  them  entirely  helpless. 

If  papules  are  formed  between  two  fingers  or  between 
two  toes,  the  epidermis  rapidly  becomes  macerated,  an 
open  sore  results,  and  the  fingers  or  toes,  as  the  case  may 
be,  become  swollen  and  livid,  and  their  proximal  extrem- 
ities cut  by  radiating  idcers.  Later  the  entire  liand  or 
foot  becomes  swollen  and  exceedingly  painful,  and,  if 
the  proper  treatment  is  not  administered  in  time,  grave 
lymphangitis  may  develop. 

If  the  papular  infiltration  attacks  the  matrix  or  mar- 
gins of  tlie  nails,  their  nutrition  becomes  seriously  im- 
paired and  syphilitic  onychia  or  paronychia  results. 
The  distal  })halanx  becomes  more  or  less  swollen ;  the  nail 
itself  very  horny,  dry,  and  brittle,  resembling  a  claw  in 
shape ;  gradually  it  separates  from  the  underlying  tissue, 
the  color  changes  to  a  dirty  yellow  or  brown,  the  nail  is 
pushed  more  and  more  forward  and  finally  cast  oif  en- 
tirely. If,  as  frequently  haiipens,  the  process  is  accom- 
panied by  sup})uration  at  the  margin,  the  patient  suffers 
intense  pain,  and  the  afflicted  member  becomes  useless, 
especially  as  several  fingers  or  toes  are  usually  affected 
at  the  same  time  or  in  rapid  succession  (Plates  30,  31a, 
31b,  32). 

The  disease  usually  lasts  several  months.  The  nails 
grow  again,  as  a  rule,  though  it  may  be  only  after  the 
lapse  of  six  months  or  even  a  longer  time. 

Secondary  Syphilitic  Phenomena  in  the  Genitalia  and 
about  the  Anus. 

In  the  secondary  period  the  genital  and  anal  regions 
are  most  frequently  the  seat  of  grave  phenomena  which 
claim  our  attentive  consideration  on  account  of  the  regu- 
larity with  which  they  appear,  tlieir  tendency  to  recur,  the 
great  danger  of  infection,  the  variety  of  different  forms, 
and,  lastly,  on  account  of  the  important  rdle  which  the 


24  SYPHILIS. 

resulting  alterations  play  in  the  diagnosis  of  visceral  dis- 
ease in  later  stages. 

It  is  generally  assumed  that  the  tissues  for  some  dis- 
tance around  an  initial  lesion  are  completely  impregnated 
with  the  syphilitic  virus,  and  are  therefore  in  a  state  of 
irritation  which  aifords  a  fertile  soil  for  the  production 
of  new  forms.  This  is  especially  true  of  the  genitals, 
where  the  irritation  is  increased  by  the  secretions,  by 
sweat,  and  by  want  of  cleanliness.  Before  the  general 
integument  becomes  diseased,  papules  frequently  appear 
at  the  edges  of  the  labia  majora  in  the  female  (espe- 
cially in  chancre  of  the  vaginal  opening)  and  on  the 
scrotum  in  the  male.  Many  people  pay  no  attention 
whatever  to  such  phenomena,  either  because  they  feel  no 
pain,  or  because  they  are  naturally  indolent  and  care- 
less, or  attribute  them  to  some  other  cause.  Hence,  rela- 
tively larger  papular  eruptions  develop  in  these  regions 
than  on  the  rest  of  the  body ;  the  surface  soon  becomes 
macerated  and  ulcers  are  formed,  with  the  production  of 
detritus,  pus,  or  only  a  serolymphoid  secretion,  according 
to  the  kind  of  degeneration  present.  These  materials  con- 
tain the  most  virulent  form-  of  the  poison  and  are  the  most 
frequent  source  of  syphilitic  infection.  The  closely  packed 
papules  are  at  first  very  shallow  ;  they  soon  run  together 
and  produce  extensive  ulcers,  speckled  on  the  surface 
and  moderately  infiltrated  at  the  base,  exuding  a  scanty 
secretion. 

Sometimes  a  diffuse  infiltration  surrounds  the  lymphat- 
ics in  the  affected  area — for  instance,  the  prepuce,  the 
skin  of  the  penis,  the  lai)ia  majora — and  the  above-men- 
tioned induratire  edema  develops. 

The  ulceration  in  genital  and  anal  syphilide  is  rarely 
deep  seated.  As  a  rule,  after  a  short  duration — four  to 
six  weeks — the  papules  begin  to  grow  upward  from  the 
base  and  often  attain  the  size  of  a  mulberry  or  a  hazelnut. 
The  proliferated  masses  are  densely  packed,  raw  on  the 
surface,  and  present  the  appearance  of  proliferating 
venereal    condylomata    acuminata   (also   called    venereal 


SECONDARY  SYPHILIS.  26 

papillomata).  Multiplying  syphilitic  papules  (papulae 
luxuiiantes)  are  distinguished  from  the  latter  by  the 
enormous  proliferation  and  infiltration  of  the  base,  which 
is  slightly  raised  above  the  level  of  the  skin,  and  the 
absence  of  the  deep  fissures  which  separate  the  individual 
venereal  papillomata  down  to  their  bases.  There  are  also 
some  anatomical  differences  between  the  two  processes, 
the  luxuriating  papular  syphilide  being  characterized  by 
an  abundant  round-celled  infiltration  in  the  papillary 
layer  of  the  skin,  while  the  papilloma  multiplies  more  in 
the  epidermis. 

In  the  perineum,  on  the  nates  (PI.  37),  and  in  the 
glandular  parts  about  the  anus  the  appearance  of  papules 
is  attended  with  the  same  conditions  as  in  the  genitalia.  In 
the  anal  region  peculiar  formations  sometimes  develop 
on  account  of  the  anatomical  relations  of  the  parts.  The 
folds  become  longer,  hard,  and  infiltrated  ;  the  intervals 
between  them  are  marked  by  deep  fissures  which  pene- 
trate into  the  aperture  of  the  anus.  These  fissures  either 
radiate  from  the  center,  or  they  may  be  placed  crosswise, 
so  that  the  infiltrated  folds  are  partially  loosened  from 
their  bases.  The  general  appearance  suggests  a  number 
of  fresh  nodules  in  process  of  formation.  The  condition 
is  painful  in  itself,  and  becomes  doubly  so  during  defeca- 
tion, so  that  even  the  most  indolent  and  careless  individuals 
are  led  to  seek  professional  advice. 

It  remains  to  be  said  that  such  processes  result  in  in- 
filtrates which  penetrate  deep  into  the  skin,  and,  in  spite  of 
the  most  energetic  treatment,  often  become  the  seat  of  new 
ulcerations.  They  are  found  by  experience  to  constitute 
the  most  frequent  source  of  syphilitic  infection.  It  is  not 
rare  to  see  papular  eruptions  suddenly  appear  in  the  geni- 
talia and  about  the  anus  after  many  years,  when  no  other 
symptoms  are  demonstrable  in  the  rest  of  the  body.  Such 
an  eruption  frequently  occurs  in  the  course  of  pregnancy 
as  a  result  of  the  venous  stasis  in  the  genitalia.  In  pros- 
titutes we  have  frequently  seen  single  glistening,  and  later 
weeping  papules  of  this  kind  appear  in  this  region,  when 


26  SYPHILIS. 

absolutely  no  other  signs  could  be  demonstrated  in  the 
rest  of  the  body  (Plates  33  to  39). 

Diseases  of  the  Buccal  Mucous  Membrane. 

The  mucous  membrane  of  the  mouth  is  almost  always 
involved  to  a  greater  or  less  degree  in  the  processes  of 
the  secondary  period,  besides  being  often  the  seat  of 
primary  lesions  as  a  result  of  direct  infection  (Plates  8  to 
11). 

Thus  we  often  see  papules  on  the  mucous  membrane 
of  the  lips  and  cheeks,  especially  if  they  are  already 
in  a  state  of  irritation  from  sharp  fragments  of  teeth,  or 
from  excessive  use  of  tobacco  or  other  irritants.  These 
papules  differ  from  those  on  the  skin  chiefly  by  their 
rapid  ulceration.  As  we  can  readily  understand,  the  dis- 
eased spot  on  the  mucous  membrane,  poorly  nourished 
through  its  base,  soon  becomes  macerated  ;  the  epithelium 
becomes  cloudy  and  of  a  pale,  whitish  color ;  as  early  as 
the  second  day  the  surface  breaks  down,  and  we  have  a 
shallow  ulcer  with  infiltrated  floor  which  bleeds  very 
easily  (Plates  40,  41a). 

Even  more  frequently  than  on  the  lips  and  cheeks  Ave 
find  papules  on  the  pillars  of  the  fauces,  the  tonsils, 
and  the  soft  palate.  They  may  be  so  numerous  on  the 
isthmus  and  in  the  throat  as  to  simulate  the  clinical 
picture  of  croup  or  diphtheria.  The  diagnosis,  however, 
is  not  difficult,  since  the  condition  is  never  accompanied 
by  rise  in  temperature,  the  course  is  slow,  and  is  fur- 
ther distinguished  by  the  presence  of  other  symptoms 
in  the  body.  Disease  of  the  tonsils  occasionally  gives 
rise  to  more  or  less  grave  functional  disturbances.  For, 
if  they  are  severely  attacked  by  the  morbid  process,  they 
become  much  enlarged,  the  isthmus  is  narrowed,  the 
patient's  voice  becomes  nasal,  and  he  suffers  from  exces- 
sive salivary  flow  and  particularly  from  dysphagia. 
Sometimes  the  crypts  break  down  and  produce  deep 
ulcers   in   the   tonsils. 


SECONDARY  SYPHILIS.  27 

If  the  papules  invade  parts  of  the  mucous  membrane 
much  exposed  to  traction,  as  the  lij)s,  angles  of  the  mouth, 
and  the  base  of  the  tongue,  deep,  cleft-like  wounds,  pene- 
trating below  the  mucous  membrane,  are  very  apt  to 
develop  and  cause  the  patient  much  discomfort. 

The  gums  are  less  frequently  attacked  by  papules 
than  the  rest  of  the  buccal  mucous  membrane.  The  gums 
appear  swollen  and  infiltrated,  and  the  ulceration  at  the 
edges  of  the  gums  often  loosens  the  teeth  in  their  sockets. 

In  advanced  cases  of  syphilis  in  the  secondary  period 
we  occasionally  meet  with  infiltrations  in  the  buccal 
mucous  membrane  which  are  remarkable  for  their  disin- 
clination to  form  ulcers.  We  have  seen  such  a  diffiise 
infiltration  in  the  soft  palate  and  uvula,  which  converted 
the  soft,  flexible  pillars  into  a  tough,  glistening  band  of  a 
dark-red  color  and  elevated  above  the  surrounding  tissue. 
The  infiltrations  shrink  and  produce  a  distortion  of  the 
velum  palati  and  a  retraction  of  the  uvula  to  one  side  or 
the  other  (PI.  42a). 

The  tongue  is  very  often  the  scat  of  secondary  syph- 
ilitic disease,  which  presents  itself  in  so  many  various 
forms  that  it  well  deserves  our  interest.  As  there  is  an 
undoubted  relation  between  mechanical  irritation  of  a 
part  and  localization  of  syphilis  in  it,  we  must  not  be 
surprised  that  the  tongue  rarely  escapes  in  a  syphilitic 
attack. 

As  early  as  the  papular  stage  individual  papillae  on  the 
dorsum  of  the  tongue  become  more  prominent  and  form 
spots  the  size  of  a  pea,  covered  with  loose,  whitish  epithe- 
lium. Later  the  epithelium  comes  oif  and  the  spots  are 
converted  into  glistening,  flesh-colored  patches,  and,  if 
the  process  of  maceration  and  disintegration  goes  on,  into 
dirty  yellow  ulcers,  raised  above  the  level  of  the  skin. 
This  is  particularly  apt  to  occur  on  the  dorsum  and  at  the 
edges  of  the  tongue,  which  are  often  intensely  irritated  by 
sharp,  decaying  teeth  or  remnants  of  teeth  ;  the  condition 
is  very  common  in  smokers  and  drinkers,  especially  if  the 


28  SYPHILIS. 

care  of  the  mouth  is  neglected.  Such  ulcers,  of  course, 
interfere  greatly  with  speaking  and  eating. 

Next  in  order  after  disease  of  individual  papillae  we 
have  a  form  which  attacks  larger  areas  on  the  surface  of 
the  tongue ;  the  affected  areas  are  sharply  circuuiscribed, 
glistening,  and  slightly  infiltrated,  with  a  tendency  to 
form  superficial  fissures  and  sores. 

In  a  third  variety,  circular  portions  of  the  mucous 
membrane,  as  large  as  a  penny,  are  converted  into  dense 
masses,  distinct  from  the  muscle  and  raised  above  the 
level  of  the  tongue.  The  surface  is  marked  by  irregular 
furrows ;  here  and  there  single,  hypertrophied  papillae  of 
a  whitish  color  project  from  the  surface. 

Another  form,  which  is  often  overlooked,  attacks  the 
region  of  the  circumvallate  papillae  or  the  adenoid  tissue 
at  the  back  of  the  tongue.  In  addition  to  the  enlarged 
and  infiltrated  papillae  themselves  there  are  other  irregular 
ulcers  which  may  defy  treatment  of  every  kind  for  a  long 
time.  Healing  is  followed  by  contracted  scars,  often  cov- 
ering large  areas  at  the  base  of  the  tongue  (PI.  41b). 

THE  TERTIARY  STAGE  OF  SYPHILIS. 

The  late  manifestations  of  syphilis  mostly  take  the 
form  of  gummata,  hence  this  stage  of  the  disease  is 
called  the  gummatous  stage,  or,  to  carry  out  the  anal- 
ogy with  the  secondary,  the  tertiary  stage.  If  these  pro- 
cesses in  the  organism  assume  a  malignant  type  and  great 
destruction  of  tissue  ensues,  with  the  additional  complica- 
tion of  amyloid  degeneration  of  internal  organs,  we  have 
the  condition  of  syphilitic  cachexia,  which  Sigmund  has 
designated  the  fourth  stage  of  syphilis. 

The  majority  of  syphilitic  patients  are  fortunate  enough 
to  see  their  disease  end  with  the  symptoms  of  the  second- 
ary stage.  The  cases  are  rare  in  which  tertiary  and 
secondary  products  are  present  at  the  same  time.  They 
constitute  what  we  have  already  referred  to  as  malig- 
nant or  precocious  syphilis.     In  these  unfortunate  indi- 


TERTIARY  SYPHILIS.  29 

vidiials  the  pustula  major  often  appears  as  the  initial 
eruption ;  at  the  same  time  tliey  are  tormented  by  peri- 
osteal gummata  (tophi),  and  before  the  end  of  six  months 
destructive  processes  begin  their  work  in  the  cavities  of 
the  mouth  and  nose.  To  make  matters  worse,  the  usual 
remedies  fail  to  arrest  the  malignant  process,  so  that  the 
patient's  life  is  often  put  in  jeopardy. 

On  the  other  hand,  it  frequently  happens  that  the 
patient  feels  perfectly  well  for  years  after  the  completion 
of  the  secondary  period,  and  is  then  suddenly  reminded 
of  his  half-forgotten  trouble  by  a  renewed  outbreak  of 
morbid  symptoms.  The  duration  of  this  latent  stage  or 
interminHion-period,  during  which  the  patient  feels  com- 
paratively well,  varies  greatly.  In  one  case  thirty-four 
years  elapsed  between  the  disappearance  of  the  secondary, 
and  the  advent  of  the  tertiary  symptoms  ;  other  observers 
put  the  duration  of  the  intermission-period  at  from  forty 
to  fifty  years. 

Within  recent  years  many  attempts  have  been  made  to 
ascertain  why  tertiary  forms  should  appear  at  all  in  certain 
cases.  Some  attribute  it  to  inadequate  treatment  or  to 
the  entire  want  of  treatment  during  the  secondary  stage; 
others  are  of  the  opinion  that  a  disposition  to  the  develop- 
ment of  gummata  may  be  produced  by  privation,  or  by 
tuberculosis,  malaria,  and  other  diseases  which  tend  to 
weaken  the  system.  As  yet,  the  controversy  is  still  in 
the  theoretical  stage,  and  the  physician  will  do  well  not 
to  make  any  promises  to  the  patient  after  the  disappear- 
ance of  the  secondary  symptoms. 

Many  authorities  assert  that,  in  addition  to  a  general 
disposition,  an  immediate  cause  is  necessary  to  produce 
gummatous  processes — for  instance,  a  blow  or  other  injury 
to  a  bone  sparingly  covered  with  soft  parts,  protracted 
excitement,  alcoholic  abuse,  in  the  case  of  nervous  dis- 
ease, etc.  This  view  served  as  the  basis  for  the  theory  of 
the  connection  between  syphilis  and  irritation,  although  it 
cannot  be  said  to  hold  true  in  every  case. 

Many  physicians  lay  down  the  universal  rule  that  the 


30  SYPHILIS. 

secretions  of  tertiary  products,  since  they  are  not  adapted 
to  the  inoculation  of  syphilis,  can  never  carry  the  syphil- 
itic contagion.  We  liave  already  referred  to  this  question 
in  the  introduction,  and  we  again  insist  that  the  proposi- 
tion must  be  accepted  with  great  caution,  and  that  it  cer- 
tainly does  not  hold  in  acute  cases. 

The  tertiary  stage  diliers  in  many  respects  from  the 
secondary,  not  only  in  the  nature  of  the  lesion  itself 
(gumma),  but  also  in  the  manner  of  its  occurrence. 

The  gumma  is  not  preceded  by  general  symptoms. 
Very  often  the  patients  are  completely  taken  by  sur- 
prise, and  only  begin  to  feel  pain  after  the  lesion  has 
actually  appeared ;  the  degree  of  pain  and  interference 
with  movement  depends  on  the  duration  and  seat  of  the 
process,  and  may  be  very  great.  It  is  only  in  consequence 
of  the  pain  and  discomfort  that  the  patients  show  emacia- 
tion and  other  signs  of  disease. 

Gummatous  processes  are  further  distinguished  from 
secondary  ones  by  the  absence  of  symmetry  in  their  dis- 
tribution or  regularity  in  their  order  of  a]ipearance.  They 
are  usually  found  only  on  one  side  of  the  body-surface,  or 
even  in  one  particular  spot,  and  they  not  only  persist  for  a 
long  time,  but  may  even  recur  in  the  same  place.  Some- 
times the  skin  and  mucous  membranes  are  the  seat  of  the 
first  appearance  of  the  gumma;  again,  the  bones  or  even 
internal  organs.  In  severe  cases  the  process  may,  how- 
ever, attack  different  parts  of  the  body  at  the  same  time. 

Gummata  really  represent  a  kiud  of  neoplasm  consist- 
ing of  granulation-tissue.  The  nodes  are  composed  of 
an  irregular  accumulation  of  granuhition-tissue,  in  which 
the  cellular  element  predominates  more  or  less  and  which 
is  in  process  of  conversion  into  connective  tissue ;  the 
normal  tissue  is  crow'ded  out  and  disappears  entirely,  or 
it  becomes  involved  in  the  degeneration  to  which  the 
syphilitic  product  itself  falls  a  victim.  At  one  stage  of 
their  development  the  tumors  possess  an  elastic  consist- 
ency, whence  the  name  *'  rubber-tumor ; "  tumors  of 
longer  standing  may  be  more  hard. 


TERTIARY  SYPiriLlS.  31 

TliG  tendency  to  degenerate  Mliieh  characterizes 
all  syphilitic  prdducts  is  shared  by  tlie  gumma  to  a  high 
degree.  It  is  ^ecn  even  in  relatively  recent  gummata ; 
the  process  begins  in  the  center  of  the  node,  destroying 
the  structure  of  the  tissue,  ^vhile  at  the  periphery  some 
ne^vly  formed  connective  tissue,  well  suj)plied  with  blood- 
vessels, remaiusand  gradually  merges  into  the  adjacent 
tissue. 

This  characteristic  property  indicates  the  subsequent 
fate  of  the  tumors.  Gummata  of  subcutaneous  and  sub- 
mucous cellular  tissue,  and  subperiosteal  gummata,  often 
undergo  ra])id  mucoid  deyenc ration.  Gummata  in  the 
glandular  organs,  liver,  testes,  and  in  the  brain  or  in  the 
muscles  undergo  ffdty  ineta)norj)Jio.sis,  and  we  may  find 
dry  caseous  masses  enclosed  in  an  area  of  newly  formed 
connective  tissue,  as  in  a  capsule,  where  it  remains  for 
years  without  undergoing  any  change. 

The  gummata  appear  as  individual  nodes  of  varying 
magnitude  ;  not  rarely,  however,  a  fresh  node  develops 
at  the  periphery  of  a  former  infiltrate,  so  that  we  see 
some  nodes  undergoing  ulceration  while  new  ones  are 
forming  about  their  periphery  {serpiginous  character). 

We  may  also  have  multiple  nodes  appearing  at  the 
same  time,  or  following  each  other  at  short  intervals,  so 
as  to  form  groups  of  gummata  ;  as  the  densely  crowded 
nodes  degenerate,  the  tissue  lying  between  them  is  de- 
stroyed, and  elliptical  or  kidney-shaped  tumors  or  ulcers 
are  formed. 

Gumma  of  the  Skin  and  Subcutaneous  Cellular  Tissue, 
The  Gummatous  Syphilide. 

Cutaneous  gunnnata  usually  appear  during  the  second 
year  after  infection,  but  may  also  occur  after  many  years 
of  comparative  good  health.  The  circiunstances  which 
we  have  referred  to  as  predisposing  the  organism  to  ter- 
tiary forms  have  the  same  effect  with  regard  to  affections 
of  the  skin,  and  we  must  further  bear  in  mind  that  the 


32  SYPHILIS. 

general  integument  of  the  body  is  more  exposed  to  injury 
than  are  the  other  tissues  and  organs. 

An  interesting  fact,  which  has  often  been  observed,  is 
that  gummata  appear  in  places  which  were  the  seat  of 
syphilitic  products  during  the  first  and  second  periods ; 
this  may  be  regarded  as  a  local  disposition  due  to  the  for- 
mer presence  of  the  virus  in  the  tissues. 

The  gumma  develops  in  the  cutis  or  in  the  subcutaneous 
cellular  tissue.  The  size  of  the  nodes  varies  from  a  pea  to 
a  pigeon's  egg  or  larger. 

If  the  gumma  is  superficial,  the  upper  layer  of  the 
skin  becomes  livid  and  shares  directly  in  the  further 
pathological  changes  of  the  gumma. 

If  the  nodes  are  seated  more  deeply,  in  the  subcutane- 
ous tissue,  the  skin  is  not  involved  until  later ;  as  the 
node  increases  in  size,  the  skin  becomes  infiltrated  and 
more  or  less  inflamed.  In  both  cases  the  skin  remains 
intact  and  recovers  its  normal  color  if  the  proper  treat- 
ment is  employed  and  the  node  is  absorbed. 

If  regeneration  is  too  slow  and  the  infiltrate  becomes 
softened,  the  skin  over  it,  which  has  meanwhile  become 
very  thin,  also  degenerates  and  an  ulcer  is  formed.  Ac- 
cording to  the  seat  and  size  of  the  nodes,  the  ulcers  are 
more  or  less  superficial,  and  the  edges  overhanging  or 
steep  and  abrupt. 

At  first,  the  floor  of  the  ulcer  is  covered  with  necrotic 
tissue ;  soon,  however,  the  scanty  purulent  secretion  of 
the  ulcer  dries,  and,  with  the  extravasated  blood,  forms  a 
dark-brown  scab  such  as  we  have  described  in  connection 
with  pustulous  ulcers  of  the  skin.  If  properly  treated, 
the  ulcer  soon  cleanses  itself  and  healthy  granulation- 
tissue  is  formed.  Scar-formation  begins  at  the  periphery 
of  the  wound,  and  a  flat  scar  eventually  remains.  Grad- 
ually the  rest  of  the  infiltrate  disappears ;  the  scar,  which 
w'as  livid  at  first,  becomes  white,  and  there  is  little  dis- 
figurement. 

If  several  nodes  develop  at  once  and  undergo  rapid 
disintegration,  large  sinuous  ulcers  result.    If  the  process 


TERTIARY  SYPHILIS.  33 

continues  and  a  new  infiltrate  is  formed  at  the  peripherVj 
the  ulcer  becomes  flattened  on  one  side,  but  extends  its 
limits  on  the  other  by  fresh  decay  of  the  infiltrate,  and  we 
thus  get  serpiginous  ulcers,  semicircular  or  reniform  in 
shape,  witii  scar-formation  at  the  center  and  ulceration  at 
the  freshly  infiltrated  periphery.  If  degeneration  is  yery 
rapid,  either  on  account  of  the  reduced  condition  of  the 
patient  or  of  unfavorable  local  conditions,  the  tissue- 
destruction  is  yery  great  and  the  ulcers  may  attain  tlie 
most  alarming  dimensions.  Thus  we  haye  seen  the  skin 
of  the  entire  lower  surface  of  the  thigh  destroyed  by  ser- 
piginous gummata. 

Under  unfayorable  conditions  the  products  of  tertiary 
syphilis,  even  more  than  those  of  the  })rimary  and  sec- 
ondary stages,  are  liable  to  gangrene.  A  tightly  fitting 
garment  pressing  on  the  gummatous  infiltrate  often  suf- 
fices to  produce  gangrene  in  an  entire  group  of  gum- 
mata ;  general  nutritive  disturbances  may  bring  about  the 
same  result.  I  remember  a  case  in  which  a  "  starving  cure  " 
(dry  rolls)  caused  the  appearance  of  dry  gangrenous  scabs 
in  eight  different  places  on  the  body.  After  the  scabs  had 
come  away,  shallow  wounds  remained  which  showed 
scarcely  a  trace  of  the  nodular  character  of  the  gumma. 

As  to  the  nature  of  the  scabs  which  form  over  gumma- 
tous ulcers,  it  may  be  said  that  sim})le  ulcers  with  mod- 
erate secretion  are  covered  with  a  scab  consisting  of  a 
single  layer ;  if  the  secretion  is  more  abundant  and  the 
ulcer  more  extensive,  the  scab  consists  of  several  strata 
resembling  an  oyster-shell,  like  those  described  in  the 
pustular  syphilide — the  so-called  rupia  of  older  writers. 

The  gummatous  processes  of  the  skin  and  subcutane- 
ous cellular  tissue  are  not  confined  to  these  structures ; 
they  often  penetrate  more  deeply  and  involve  the  under- 
lying muscles,  bones,  and  joints  (see  PI.  55).  Myositis, 
caries  of  the  bones,  and  even  necrosis  not  infrequently 
accompany  an  advanced  gummatous  process,  so  that  the 
disease  becomes  more  dangerous,  and  worse  consequences 
result.    The  tissues  may  be  injured  directly  by  the  spread- 


34  SYPHILIS. 

ing  gummata,  or  the  resulting  scars  may  be  so  extensive 
as  to  produce  deformities  or  even  destroy  the  movability 
of  the  limbs.  In  some  cases  the  scars  swell  and  pro- 
liferate, forming  shapeless  wheals  (keloids)  which  may  be 
present  on  the  skin  side  by  side  with  gummatous  sores. 

Before  leaving  the  subject  of  gummatous  affections  of 
the  skin,  of  which  there  are  such  countless  varieties,  pre- 
senting ever-varying  pictures,  we  would  mention  a  mas- 
sive infiltration,  one  of  the  later  forms  of  syphilis,  which 
we  prefer  to  designate  diffuse  hypertrophic  syphil- 
oma or  syphilitic  leontiasis  instead  of  syphilitic 
lupus.  This  form  only  appears  long  after  the  completion 
of  the  secondary  stage.  It  develops  slowly,  and  is  dis- 
tinguished from  the  simple  gummatous  forms  by  its  per- 
sisting for  a  long  time  without  undergoing  any  marked 
change.  It  occurs  in  the  form  of  hard,  plate-like  infil- 
trates on  the  lips,  nose,  and  tongue.  The  infiltrate  occu- 
pies the  entire  thickness  of  the  ]>arts  mentioned,  which 
eventually  become  quite  immovable.  The  surface  shows 
slight  ulceration  in  places,  but  the  process  never  attains 
the  same  depth  and  lateral  extension  as  in  the  case 
of  gummata.  In  every  instance  energetic  antisyphilitie 
treatment  is  followed  by  absorption  and  healing  of  the 
sores ;  but  for  years  afterward  the  site  of  the  disease 
is  marked  by  a  moderate  thickening  of  the  connective 
tissue. 

Syphilis  of  the  Motor  Apparatus. 

As  we  have  already  remarked,  the  gummatous  disease 
of  the  skin  and  subcutaneous  tissue  occasionally  spreads 
to  the  underlying  bones  and  muscles ;  bones  which  have 
but  a  thin  covering  are  chiefly  affected,  as  the  anterior 
aspect  of  the  tibia,  the  cranium,  sternum,  clavicle,  ulna, 
etc.  (see  Plates  52a,  55). 

The  skin  is  naturally  thin  over  these  bones,  and,  if 
gummata  develop,  tiie  bones  very  soon  become  involved, 
the  periosteum  is  destroyed  almost  as  fast  as  the  skin 


TERTIARY  SYPHILIS.  35 

itself,  and  tho  bones  are  left  entirely  exposed.  If  the 
proper  treatment  is  employed,  the  patients  may  escape 
with  a  slight  granular  exfoliation  of  the  bone ;  if,  how- 
ever, the  tissue-destruction  is  extensive,  and  large  portions 
of  the  bone  are  exposed,  caries  usually  sets  in  and  the 
bone  is  more  or  less  completely  destroyed.  The  bones 
which  we  have  enumerated — including,  perhaps,  the  ribs 
— often  become  the  seat  of  spontaneous  periostitis.  Pain- 
ful, slightly  raised  })atches  appear  over  the  bone  and  increase 
steadily  in  size  ;  unless  the  process  is  arrested  by  the  proper 
treatment,  the  skin  becomes  inflamed,  and  soft  ulcers  (tophi) 
are  formed  which  rupture  toward  the  surface  and  discharge 
a  mucous  secretion. 

Gummata  proceeding  from  the  skin,  and  involving  the 
periosteum  secondarily,  find  their  analogue  in  a  similar 
affection  of  the  mucous  membrane  and  the  thin  bones 
lying  beneath  it.  The  palate  and  the  septum  of  the 
nose  are  chiefly  affected  ;  the  periosteum  is  destroyed  by 
the  ulceration  in  a  few  days,  and  the  bones  are  laid  bare 
and  fall  victims  to  caries  and  necrosis. 

So-called  fibrous  gummata  frequently  spring  from  the 
periosteum ;  these  gummatous  tumors  do  not  undergo  the 
retrogressive  metamorphosis  and  rapid  decay  which  we 
have  described  ;  they  are  hard  and  dense  in  structure,  and 
embedded  in  a  depression  in  the  surface  of  the  bone  as  in 
a  niche.  They  yield  to  appropriate  treatment  by  under- 
going absorption,  but  they  constitute  a  serious  disease 
on  account  of  their  origin,  duration,  and  the  amount  of 
destruction  they  cause  in  the  bone.  The  surrounding 
portions  of  the  bone  become  thickened  and  sclerosed. 
Such  slightly  raised  hyperplasia  are  seen  after  periosteal 
processes  of  long  standing  in  the  flat  bones  of  the  sk-ull, 
the  anterior  aspect  of  the  tibia,  etc. 

Another  form  of  gummatous  disease  of  the  bones,  both 
long  and  flat,  is  osteomyelitis ;  in  the  long  bones  the 
process  starts  in  the  marrow,  in  the  flat  bones  from  the 
spongv  substance,  or  from  the  diploe  in  the  case  of  the 
skull." 


36  SYPHILIS. 

The  patients  complain  of  boring  pain,  which  usually 
comes  on  at  night,  a  long  time  before  any  enlargement 
of  the  bone  is  noticeable.  I  am  reminded  in  this  con- 
nection of  a  very  instructive  case  of  pneumonia,  in  which 
gummata  were  found  in  several  of  the  long  bones  at  the 
autopsy  (osteomyelitis  gtiinmosa). 

The  disease  can  undoubtedly  exist  for  some  time  Avith- 
out  producing  any  noticeable  alterations,  until  finally  the 
dense  shell  of  the  bone  becomes  enlarged  or  a  central 
necrosis  develops.  The  bones  of  syjihilitic  patients 
sometimes  show  a  tendency  to  fracture  from  the  most 
trivial  causes ;  such  cases  are  usually  characterized  by 
great  shortening  of  the  bone  and  disinclination  to  unite 
{spontaneous  fracture  in  gummatous  osteomyelitis). 

In  all  such  cases,  whether  they  originate  in  a  perios- 
titis or  in  an  osteomyelitis,  if  the  bone  is  macerated,  the 
center  is  found  to  be  rarefied,  while  the  substance  in  the 
periphery  is  increased  in  density. 

If  large  portions  of  the  periosteum  are  destroyed,  or 
if  several  gummata  exist  side  by  side  in  the  marrow,  so 
that  a  large  part  of  the  bone  is  deprived  of  its  nutrition, 
necrosis  sets  in  and  the  affected  portions  of  the  bone  are 
cast  off  as  sequestra.  If  the  soft  parts  become  inflamed 
and  ulcerate,  caries  also  results. 

Smaller  long  bones  like  the  clavicle  and  the  ])halanges 
become  rarefied  by  extensive  gummatous  infiltrations  and 
produce  the  condition  known  as  Spina  ventosa.  It  has 
been  observed  in  the  clavicle  and  also  in  the  phalanges 
after  syphilitic  dactylitis. 

Joints. — The  synovial  membranes  of  joints  suffer  in 
the  same  way  as  the  periosteum,  especially  in  the  painful 
swellings  of  the  joints  which  often  occur  in  the  early 
stages  of  syphilis  (syphilitic  arthromeningitis). 
Several  large  joints  may  become  swollen,  presenting  the 
picture  of  articular  rheumatism,  and  the  diagnosis  may 
be  obscured  by  the  exudation  into  the  cavities  of  the 
joint,  by  the  pain,  and  by  the  fever  which  is  occasionally 
present.     The  condition  is  distinguished  from  rheumatism 


TERTIARY  SYPHILIS.  37 

by  the  remittent  type  of  the  fever,  the  accompanying 
phenomena  in  the  skin  and  mucous  membranes,  and  by 
the  shorter  duration,  especially  if  antisyphilitic  measures 
are  employed. 

The  prognosis  in  these  acute  forms  of  synovitis  is  fav- 
orable ;  if  they  are  neglected,  however,  or  if  a  cold-water 
treatment  is  resorted  to,  ankylosis  results;  there  may  even 
be  crepitation,  showing  that  erosion  has  begun  in  the  car- 
tilaginous investment. 

But  the  syphilitic  affections  of  the  tertiary  period  are 
much  more  important  than  the  disease  we  have  just  men- 
tioned ;  grave  alterations  in  the  affected  joint  are  almost 
invariably  the  result.  We  refer  to  gummatous  disease  of 
the  bones  or  of  the  epiphyses,  which  have  involved  the 
joint,  and  })eri-articular  gummatous  processes  involving 
the  fibrous  capsules  and  ligaments,  which  have  extended 
to  the  synovial  membranes.  Such  articular  cavities  con- 
tain little  serous  exudation  and  are  filled  with  adhesions, 
villous  excrescences,  and  ])artially  detached  fragments  of 
gummatous  synovial  membrane. 

The  usual  outcome  in  grave  oases  of  syphilitic  joint- 
disease  is  fibrous  ankylosis,  even  if  the  syphilitic  pro- 
cess is  peri-articular.  More  rarely  peri-articular  gum- 
mata  rupture  toward  the  surflice,  and  continue  to  ulcerate 
until  they  break  tlirough  to  the  articular  cavity  and  set 
up  a  purulent  articular  inflannnation.  Speedy  surgical 
interference  becomes  necessary  in  such  cases,  as  anti- 
syphilitic  treatment  is  found  to  be  useless. 

Muscles. — The  muscles  also  appear  to  be  attacked 
early  in  the  coiirse  of  syphilis  by  rheumatic  pains.  But 
both  the  primary  and  secondary  forms  usually  disappear 
of  their  own  accord  and  leave  no  permanent  conse- 
quences. 

When  gummatous  disease  of  the  skin  and  subcutaneous 
tissue  penetrates  to  the  muscles,  the  condition  is  more 
serious. 

The  muscle  may  also  become  the  ])rimarv  seat  of  a 
gummatous    infiltration    (myositis    gummosa).     The 


38  SYPHILIS. 

muscular  gummata  may  attain  a  considerable  size,  as 
large  as  a  hen's  egg,  and  the  course  and  location  are 
sometimes  such  as  to  cause  them  to  be  mistaken  for 
tumors,  especially  sarcomas.  The  disease  begins  with  a 
round-celled  infiltration,  starting  in  the  perimysium  and 
those  layers  of  the  connective  tissue  whicli  still  contain 
blood-vessels ;  large  portions  of  the  perimysium  become 
involved,  and  the  transverse  marking  of  the  muscle-sub- 
stance itself  is  gradually  lost. 

If  such  a  gumma  ulcerates,  the  muscle-substance  may 
undergo  necrosis  and  decay.  As  a  rule,  however,  muscu- 
lar gummata  undergo  fatty  degeneration,  and  a  cheesy 
mass  of  rather  dense  connective  tissue  becomes  encapsuled. 
After  the  necrosed  tissue  has  been  cast  off  or  absorbed, 
an  extensive,  fibrous  scar,  composed  of  the  connective 
tissue  which  surrounds  the  gummata  in  large  masses, 
remains,  which  destroys  the  function  of  any  muscles  that 
may  be  still  intact,  so  that  the  extremities  invariably  be- 
come disabled  (PI.  55). 

The  infiltrative  process  frequently  involves  the  ten- 
dons, especially  the  point  of  union  with  the  muscle.  All 
the  tendons  in  the  body  are  liable  to  the  disease ;  we  have 
observed  it  particularly  in  the  tendo  Achillis  and  in  the 
ligamentum  patellae. 

The  sheaths  of  the  tendons  are  also  occasionally 
the  seat  of  an  extensive  gummatous  hyperplasia  (PI.  52). 
After  a  long  time  the  infiltrate  finally  comes  away  spon- 
taneously, but  it  is  best  to  assist  the  process  by  surgical 
interference. 

Syphilis  of  the  Lymphatic  Apparatus. 

This  heading  includes  diseases  of  the  lymphatic  glands, 
the  tonsils,  the  follicles  in  the  isthmus  and  in  the  throat, 
the  spleen,  the  thyroid  gland,  and  the  suprarenal  cap- 
sules. 

The  characteristic  glandular  swcUing  of  the  primary 
stage  finds  its  analogue  in  the  general  glandular  enlarge- 


TERTIARY  SYPHILIS.  39 

ment  which  occurs  when  the  entire  organism  has  become 
infected.  It  often  makes  its  appearance  before  the  skin- 
symptoms,  but  is  sure  tt)  become  aggravated  if  tiiere  is 
secondary  ulceration  in  the  skin  and  mucous  membranes. 
In  general,  the  glands  are  found  to  be  more  enlarged  in 
scrofulous  individuals  and  in  those  who  have  been  weak- 
ened by  disease.  Swollen  lymph-glands  are  often  found 
in  parts  of  the  body  (as  the  side  of  the  thorax)  where  no 
glands  can  be  felt  normally.  In  the  secondary  period  we 
can  usually  feel  the  inguinal  glands,  the  cervical  glands — 
from  the  mastoid  ])iocess  along  the  sternomastoid  as  far 
as  the  supraclavicular  fossa — the  axillary  glands  under  the 
anterior  margin  of  the  pectoralis,  the  glands  of  the  elbow 
over  the  internal  condyle,  etc.  In  autopsies  on  syphilitic 
subjects  we  have  also  found  the  internal  glands  swollen. 
The  enlargement  develops  slowly  and  gives  rise  to  elon- 
gated, spindle-shaped,  hard  nodes,  although  sometimes 
the  spherical  shape  is  retained.  The  glands  shrink  to 
their  minimum  with  proper  treatment.  At  first  the 
glands  appear  reddish-brown  in  cross-section  ;  later,  the 
hilus  becomes  filled  with  connective  tissue  and  sometimes 
with  large  masses  of  adipose  tissue,  so  that  the  cortical 
substance  of  the  gland   is  nuich  reduced  in  thickness. 

We  have  frequently  observed  glandular  enlargement  in 
the  tertiary  period.  It  is  spontaneous  and  attains  the 
size  of  a  ])igeon's  or  a  hen's  egg ;  it  disa])i)ears  if  potas- 
sium iodid  is  given,  and  recurs  either  in  the  same  or  in 
other  groups  of  glands.  Glandular  disease  sometimes 
coexists  with  gummatous  swellings  in  the  skin  ;  if  the 
gummata  are  undergoing  suppuration,  they  frequently  give 
rise  to  glandular  swelling  (PI.  54).  Glandular  swelling 
is  not  always  directly  associated  with  cutaneous  gummata, 
and  must  therefore  be  regarded  as  a  si)ecial  disease, 
since  we  often  observe  giunmata  in  the  skin  and  subcu- 
taneous tissue  without  any  glandular  swelling  whatever. 

These  gummatous  processes  in  the  glands  may  lead  to 
caseous  degeneration,  and  the  cheesy  masses  may  remain 
encapsuled  for  a  long  time.     The  process  may,  hoMever, 


40  SYPHILIS, 

start  in  the  glands  and  involve  the  skin  secondarily,  pro- 
ducing inflammation  and  finally  suppuration  and  necrosis; 
a  typical  case  of  this  kind  is  shown  in  PI.  53.  In  time 
the  gland  itself  undergoes  exfoliation  (PI.  54),  and  a  scar 
results. 

Spleen. — The  spleen  does  not  necessarily  become 
swollen  during  the  acute  stage  in  every  case  of  syphilis. 
But  in  a  large  number  of  cases,  especially  those  in  which 
the  eruptive  stage  is  complicated  with  chloraneniia,  a  splenic 
enlargement  can  be  demonstrated  by  palpation  and  per- 
cussion. It  disappears  when  antisyphilitic  remedies  are 
given,  just  like  the  exanthemata  of  the  secondary  period. 
More  rarely  the  organ  remains  indurated,  the  splenic  pulp 
becoming  harder  and  dryer;  the  connective  tissue  of  the 
trabecuhe  and  capsule  becomes  thickened,  and  the  latter 
may  be  attached  to  neighboring  tissues  by  adhesions. 
These  splenic  tumors  mostly  occur  in  conjunction  with 
disease  of  the  liver,  stomach,  intestine,  and  kidneys. 

Gummatous  neoplasms  have  been  observed  as  nodes  of 
varying  size  in  tlie  interior  of  the  organ,  or  more  fre- 
quently beneath  the  capsule.  They  usually  undergo 
fatty  or  cheesy  degeneration,  and  can  probably  remain 
encapsuled  within  the  spleen  as  a  dry  mass  for  a  long 
time. 

This  circumscribed  form  of  splenitis  cannot  be  dis- 
tinguished during  life  from  the  indurative  diffuse  variety 
which  has  been  described.  Anatomically  such  fatty  or 
cheesy  foci  closely  resemble  infarcts ;  it  is  often  difficult 
to  distinguish  them  from  caseous,  solitary  tubercles. 
Sometimes  a  similar  localized  degeneration  of  the  paren- 
chyma is  produced  by  a  syphilitic  endarteritis. 

The  spleen  is  more  frequently  the  seat  of  amyloid 
degeneration  than  other  internal  organs  in  those  who 
have  died  of  syphilitic  marasmus ;  often  we  find  amyloid 
disease  in  the  s])leen  alone,  the  other  organs  being  entirely 
free,  or  showing  only  traces  of  it. 

Gummata  have  also  been  observed  in  the  thyroid 
gland  and  in  the  suprarenal  bodies ;  they  are,  how- 


TERTIARY  SYPHILIS.  41 

ever,  extremely  rare,  and  liave  so  far  only  been  found 
accidentally. 

Syphilis  of  the  Digestive  Tract.  ' 

Oral  Cavity. — We  have  seen  that  the  mucous  mem- 
brane of  the  oral  cavity  is  almost  always  involved  during 
the  secondary  period.  Papules,  ulcers,  and  fissures  are 
constantly  found.  The  alterations  which  are  produced 
in  the  tertiary  stage  are  known  as  syphilitic  pachydermia, 
or  psoriasis  mucosce  oris  ;  they  occur  in  the  mucous  mem- 
brane of  the  tongue,  the  cheeks,  especially  opposite  the 
teeth,  and  in  several  other  localities.  The  characteristic 
sign  is  a  thickening  of  the  mucous  membrane,  with  the 
formation  of  whitish  patches,  consisting  of  several  layers 
of  })roliferated  epithelium  almost  as  hard  and  horny  as 
epidermis.  Other  irritants  besides  syphilis  have  a  share 
in  the  production  of  these  patches,  such  as  mechanical 
irritation  by  rough  projections,  sharp  or  decayed  teeth, 
tobacco-chewing,  smoking,  and  alcohol.  The  condition 
is  incurable,  and  is  very  distressing  to  the  patient  on 
account  of  the  tendency  to  form  open  sores ;  the  j)atches 
are  extremely  vulnerable,  and  possess  absolutely  no  elas- 
ticity, so  that  a  morsel  of  hard  food  suffices  to  make  an 
abrasion  (Plates  41b,  42b).  Rarely,  submucous  gummata 
form  under  these  whitish,  epithelial  layers ;  much  more 
frequently  epitheliomata  develop. 

Gummata  in  the  oral  cavity  proceed  from  the  submu- 
cosa,  but  they  invade  the  mucous  membrane  so  rapidly 
that  it  is  very  hard  to  determine  whether  they  really 
sprang  from  the  mucous  membrane  or  from  the  sub- 
mucosa.  They  are  usually  found  on  the  tongue,  the 
palate,  the  isthmus  of  the  fauces,  and  the  nasopharyn- 
geal cavity. 

The  Tongue. — There  is  scarcely  an  organ  in  which 
syphilis  deposits  so  many  and  such  various  pathological 
products  as  in  the  tongue.  The  later  stages  of  secondary 
syphilis  are  often  marked  by  papular  eruptions  and  ulcer- 
ation along  the  margin  of  the  tongue  and  by  extensive 


42  SYPHILIS. 

rnfiltration  on  the  surface.  Among  the  tertiary  forms  we 
count  alterations  of  the  surface,  so-called  psoriasis  or  leu- 
koplasia  of  the  tongue.  We  may  also  luention  smooth 
atrophy  of  the  root  of  the  tongue  {atrophia  kevis  baseos 
linguoe),  which,  like  psoriasis,  is  a  persistent  alteration 
and  assumes  a  diagnostic  significance  in  doubtful  cases 
of  syphilitic  disease  of  internal  organs.  The  process 
must  not  be  confounded  with  cicatricial  formations  in 
this  region,  to  which  we  liave  referred  among  the  sec- 
ondary aifections.  The  atrophy  develops  without  the 
patient's  knowledge,  probably  in  consequence  of  the 
lymphatic  apparatus  becoming  involved,  and  corresponds 
to  similar  conditions  in  other  tissues  in  syphilitic  disease, 
as,  for  instance,  atrophy  of  the  heart-muscle.' 

The  development  of  a  gumma  in  the  tongue  is  a  more 
frequent  event.  The  gumma  starts  in  the  submucosa, 
and  rapidly  destroys  the  mucous  membrane ;  but  it  soon 
heals  and  leaves  a  scar,  if  properly  treated.  If  a  large 
gumma,  or  several  smaller  ones  ])laced  close  together, 
develop  in  the  submucous  and  muscular  tissue,  the  tongue 
becomes  greatly  swollen,  and,  if  the  growth  cannot  be 
arrested,  the  swelling  soon  softens.  The  mucous  mem- 
brane is  destroyed  and  a  reddish-brown  mass  is  dis- 
charged. The  cavity  which  remains  is  often  quite  deep, 
and  shaped  like  a  fissure ;  its  floor  of  a  whitish  color 
and  covered  with  necrotic  tissue.  The  tumors  or  ulcers 
are  exceedingly  painful  and  often  prevent  the  patients 
from  chewing  and  speaking,  so  that  they  soon  become 
reduced  in  weight  and  strength. 

If  the  gummata  persist  a  long  time,  or  recur  frequently, 
they  may  give  rise  to  epitheliomata.  It.  is  often  difficult, 
on  account  of  the  cachectic  appearance  of  the  patient,  to 
decide  if  he  is  suffering  from  a  gumma  or  from  a  neo- 
plasm. But  carcinoma  can  be  distinguished  from  a 
gumma  by  the  lancinating  pain,  the  condition  of  the 
glands,  and,  finally,  by  the  failure  of  antisyphilitic  rem- 
edies, so  that  the  diagnosis  is  soon  cleared  up  (PI.  57). 

*  See  Nothnagel's  Pathology;  Kraus's  Diseases  of  the  Oral  Cavity. 


TERTIARY  SYPHILIS.  43 

Gummata  in  the  tongue  leave  eicatricial  contractions  which 
may  interfere  materially  with  the  use  of"  the  member  and 
lead  to  injury  and  recurrence  of"  the  gumma,  sometimes 
even  to  the  development  of  an  epithelial  cancer. 

The  base  of  the  tongue,  the  significance  of  which  has 
already  been  referred  to,  is  often  the  seat  of  gummatous 
neoplasms.  They  form  in  the  adenoid  tissue  and  produce 
ulcers  and  infiltrations  which  at  first  cause  the  patient  no 
discomfort  and  tiierefore  often  escape  detection.  Unless 
the  ulceration  persists  for  a  long  time,  the  patients  are 
not  likely  to  have  themselves  examined.  Palpation  with 
the  finger  is  as  important  in  the  diagnosis  as  inspection  by 
means  of  the  larvno-eal  mirror.  The  differential  diag-nosis 
from  tuberculous  ulcers  and  degenerated  epitheliomata  is 
undeniably  difficult,  and  is  based  solely  on  the  presence 
of  other  syphilitic  signs  and  on  the  result  of  treatment. 

Tiie  junction  of  the  hard  with  the  soft  palate  is  a  favor- 
ite seat  of  gummatous  neoplasms,  distinguished  from 
all  others  by  their  rapid  decay ;  before  the  patient  has 
become  aware  of  the  disease,  sometimes  in  a  single 
night,  a  perforating  ulcer  develops.  If  the  proper 
treatment  is  applied  immediately,  it  may  be  possible 
to  arrest  the  process  and  close  the  perforation,  or  at 
least  to  save  a  large  part  of  the  soft  palate,  so  that  the 
perforation  can  be  closed  by  operative  means  after  the 
ulceration  has  healed.  But  if  the  patient  neglects  to  seek 
medical  assistance,  disintegration  progresses  rapidly,  and 
after  one  or  two  weeks  but  a  few  slireds  remain  of  the 
edge  of  the  soft  palate,  from  which  hangs  the  infiltrated 
uvula.  If  these  last  remaining  shreds  tear  through,  the 
swollen  uvula  may  be  sucked  into  the  air-tube  and  cause 
symptoms  of  asphyxia,  so  that  it  is  best  under  such  cir- 
cumstances to  remove  it.  The  mildest  result  of  such  a 
destruction  of  the  palate  is  a  cicatricial  distortion  of  the 
isthmus  of  the  fauces ;  usually  the  arches  are  also  in- 
volved in  the  degeneration. 

Gummata  in  the  hard  palate  undergo  decay  just  as 
rapidly,  whether  they  arise  from  the  submucosa  or  from 


44  SYPHILIS. 

the  periosteum,  and  a  perforation  soon  follows.  The  bone 
itself  is  attacked  by  caries,  and  in  a  short  time  a  large 
sequestrum  is  detached,  or  the  bone  gradually  crumbles 
and  the  detritus  is  discharged.  A  communication  is 
established  between  the  oral  cavity  and  the  posterior 
nares,  which  causes  the  patient  much  distress  even  after 
the  formation  of  a  scar,  as  the  taking  of  liquid  and  soft 
food,  as  well  as  speaking,  becomes  impossible.  Some 
patients  remedy  the  trouble  by  means  of  tampons,  but 
it  is  better  to  close  the  opening  with  a  rubber  plate,  or, 
if  the  loss  of  substance  has  not  been  too  great,  by  oper- 
ative means  (Plates  56a,  56b). 

Gummatous  disease  is  sometimes  primary  in  the  pos- 
terior wall  of  the  pharynx,  starting  in  the  pharyn- 
geal tonsils,  but  it  is  more  frequently  secondary  to  disease 
in  the  nares  or  in  the  isthmus  of  the  fauces.  In  an  in- 
credibly short  time  the  mucous  membrane  is  converted 
into  a  large  ulcer  by  the  rapid  spread  of  the  destructive 
process,  and  the  pharyngeonasal  cavity  is  occluded  pos- 
teriorly ;  the  destruction  may  extend  to  the  periosteum 
and  even  to  the  turbinate  bones  (PI.  56b). 

The  resulting  deformities  depend,  of  course,  on  the 
degree  of  destruction. 

Even  in  the  event  of  a  cure  certain  deformities  remain, 
depending  upon  the  degree  of  tissue-destruction.  The 
communication  between  the  nose  and  throat  is  partially  or 
completely  cut  off  by  cicatricial  contraction  of  the  remains 
of  the  soft  palate  and  of  the  pillars  of  the  fauces.  This 
has  the  eifect  of  drawing  the  base  of  the  tongue  against 
the  posterior  wall  of  the  pharynx,  although  a  small  open- 
ing may  still  maintain  some  communication  with  the  esoph- 
agus and  the  larynx.  Swallowing  becomes  so  difficult  that 
operative  measures  must  sometimes  be  resorted  to.  Respira- 
tion is  also  impaired  when  the  nasojiharyngeal  cavity  is 
closed,  as  the  patient  is  forced  to  breathe  through  the  nose. 
This  gives  rise  to  laryngeal  troubles,  bronchial  catarrh,  and 
deeper  processes  which  interfere  with  the  respiration  even 
more  seriously. 


TERTIARY  SYPHILIS.  45 

The  ear  is  seriously  affected  by  ulcerations  in  the 
pharynx ;  the  orifices  of  the  Eustachian  tubes  are  de- 
stroyed, delicacy  of  hearing  is  lost,  and  the  patient 
suffers  severe  stabbing-pains.  If  the  disease  attacks  the 
.middle  ear,  grave  lesions  of  the  organ  of  hearing  may 
result. 

The  mucous  membrane  of  the  cheeks  and  lips 
and  the  gfums  are  least  frequently  the  seat  of  gumma- 
tous ulcers.  If  gunmiata  and  infiltrations  do  appear, 
they  are  usually  situated  on  the  lips,  along  the  alveolar 
border  (PI.  41a).  Such  ulcers  do  not  differ  materially 
from  those  we  have  described.  They  may  assume  diag- 
nostic importance  in  differentiation  from  tuberculous 
destruction  of  the  mucous  membrane  or  from  epithelial 
cancer.  In  this  connection  it  may  be  briefly  mentioned 
that  tuberculous  nodules  are  very  often  seen  at  the  pe- 
riphery of  tuberculous  ulcers,  and  that  the  floor  never 
possesses  the  enormous  infiltration  which  is  characteristic 
of  syphilis  ;  moreover,  tubercular  disease  is  rarely  pri- 
mary in  this  situation  ;  we  usually  find  at  the  same  time 
advanced  disease  of  the  respiratory  tract. 

The  course  of  epithelial  cancer  is,  generally  speaking, 
slower  than  that  of  syphilitic  processes,  especially  gum- 
matous infiltrations  of  the  mucous  membranes.  In 
syphilis  the  submaxillary  glands  rarely  become  swollen, 
while  they  are  always  involved  in  cancer  after  it  has  per- 
sisted some  time.  Lastly,  the  diagnosis  can  be  confirmed 
by  means  of  the  therapeutic  measures  which  have  been 
referred  to. 

The  salivary  gflands  have  occasionally  been  observed 
to  become  diseased  in  syphilis. 

KsophagUS. — Syphilitic  disease  of  the  esophagus  is 
usually  diagnosed  at  the  autopsy.  The  esophagus  is  never 
attacked  primarily,  but  becomes  secondarily  involved  in 
disease  of  the  mediastinal  glands  and  of  the  pharynx. 
Gummata  in  the  mediastinal  glands  break  through  the 
wall  of  the  esophagus,  the  mucous  membrane  is  destroyed, 
and  constricting  scars  result. 


46  SYPHILIS. 

Stomach. — Acute  or  subacute  gastric  catarrh  occur- 
ring in  tlie  early  stage  is  very  rarely  tlie  direct  result  of 
syphilis.  It  may  possibly  be  considered  so  in  cases 
where  it  forms  a  sequel  to  existing  syphilitic  disease  of 
the  liver  or  kidneys. 

Ulcers  consisting  of  gummatous  infiltration  of  the  sub- 
mucosa  occur  in  the  stomach  as  the  direct  products  of 
syphilis.  They  are  often  discovered  at  the  autopsy, 
usually  in  the  region  of  the  pylorus  and  the  lesser  curva- 
ture, but  occasionally  also  at  the  cardiac  extremity ;  the 
infiltration  develops  in  the  subraucosa  and  spreads  to  the 
mucous  and  also  to  the  serous  coats  of  the  stomach.  In 
addition  to  ulcerations,  gummatous  infiltrates  and  scar- 
formation  have  been  found,  so  that  it  is  fair  to  conclude 
that  cicatrization  of  gummatous  ulcers  in  the  stomach  is 
possible. 

In  rare  instances  we  find  ulcers  due  to  syphilitic  arte- 
ritis of  the  gastric  vessels ;  they  resemble  the  round  gas- 
tric ulcer  both  in  their  clinical  characters  and  in  their 
anatomical  appearance. 

Intestine. — Acute  intestinal  catarrh,  or  chronic  ente- 
ritis, occurring  in  constitutional  syphilis,  cannot  be  diag- 
nosed in  vivo  ;  they  not  infrequently  accompany  syphilitic 
disease  of  the  liver,  such  as  amyloid  degeneration,  and 
therefore  do  not  belong  to  the  syphilitic  process. 
.  Ulcers,  however,  undoubtedly  do  occur  in  the  intestine 
as  the  direct  result  of  syphilis,  but  our  knowledge  of 
them  is  chiefly  derived  from  accidental  discoveries  at  the 
autopsy-table.  They  are  usually  multiple  and  localized 
in  the  small  intestine,  especially  in  the  uj^per  part.  They 
usually  develop  from  peculiarly  rigid  infiltrates,  corre- 
sponding in  position  to  the  Peyer's  patches,  which  pene- 
trate the  mucous  membrane  and  the  submu(!Ous  and  mus- 
cular layers,  as  large  as,  or  larger  than,  a  dollar.  The 
mucous  membrane  is  destroyed  and  irregular  cavities 
remain,  almost  circular  in  shape  and  placed  transversely 
to  the  axis  of  the  gut,  with  punched-out  edges  of  mucous 
membrane  and  a  rigid  floor,  either  covered  with  a  grayish 


TERTIARY  SYrillLIS.  4? 

secretion  or  consisting  of  scar-tissue.  The  serous  coat 
hypertrophies,  and  false  membranes  are  formed  which 
may  occhide  portions  of  the  intestine.  The  scars  which 
remain  are  flat  and  cause  some  stenosis. 

In  the  large  intestine  the  occurrence  of  grave  dis- 
turbances is  more  common.  Infiltrations  of  the  anal  folds 
and  the  fissures  between  them  spread  to  the  large  intes- 
tine, or  gummatous  processes  in  the  mucous  membrane  of 
the  anus  and  in  the  perirectal  tissues  extend  upward. 
The  symptoms  usually  consist  in  the  passing  of  muco- 
purulent matter,  diarrhea,  tenesmus,  hemorrhages,  and 
e\'en  prolapse  of  the  diseased  parts. 

After  a  time  the  connective  tissue  increases  greatly 
and  pronounced  constriction  of  the  lumen  results.  This 
is  a  grave  condition,  and  the  patient  rapidly  becomes  re- 
duced by  the  intense  pain,  the  fever,  loss  of  blood,  and 
excessive  secretion  in  the  bowel.  Purulent  periproctitis 
and  even  ])eritonitis  may  supervene  and  bring  about  the 
death  of  the  patient. 

The  I/iver. — Of  all  the  internal  organs  the  liver  is 
the  most  frequent  seat  of  the  process.  Whenever  the 
internal  organs  are  attacked  by  syphilis  it  is  safe  to 
assume  that  the  liver  is  involved,  even  if  the  disturb- 
ances in  other  organs  are  the  most  prominent  symptoms. 
The  liver  may  also  be  the  only  organ  diseased.  Two 
forms  are  distinguished  :  interstiiial  and  gummatous  hepa- 
titis. The  two  pathological  alterations  are  nearly  always 
associated ;  sometimes  only  portions  of  the  organ  are  in- 
volved, sometimes  the  entire  liver. 

Hepatic  gummata  form  larger  or  smaller  nodes,  usually 
about  the  size  of  a  hazelnut,  either  single  or  disposed  in 
groups  so  as  to  form  tumors  the  size  of  a  hen's  q^^.  They 
are  rather  more  common  in  the  right  lobe,  and  particularly 
affect  the  junction  between  the  two  lobes,  under  the  sus- 
pensory ligament.  They  are  usually  found  in  a  condition 
of  necrosis  or  caseous  degeneration,  enclosed  in  strands  of 
connective  tissue  of  varying  density  which  radiate  more  or 
less  irregularly  into  the  surrounding  parenchyma,  dividing 


48  SYPHILIS. 

the  liver-siibstance  into  irregular  islands.  The  proliferat- 
ing gummatous  granulation-tissue  encroaches  upon,  and 
finally  obliterates  the  liver-tissue,  leaving  only  the  smaller 
bile-ducts.  The  latter  may  be  greatly  hypertrophied. 
Gradually  the  cheesy  masses  are  absorbed,  the  granula- 
tion-tissue partly  disappears  or  becomes  converted  into 
fibrous  connective  tissue,  deep,  contracting  scars  appear 
on  the  surface,  marking  off  whole  sections  of  the  organ — 
the  hepar  lobatum.  If  large  numbers  of  gimimata  are 
massed  in  one  situation  or  in  one  lobe,  large  areas  or  an 
entire  lobe  may  disappear.  If  the  gummatous  process 
extends  over  the  entire  organ,  thero  is  a  general  increase 
in  the  connective  tissue,  subdividing  the  parenchyma  into 
small  islands — so-called  syphilitic  cin^hosis.  It  is  charac- 
terized by  an  unequal  distribution  of  the  connective  tissue, 
abundant  at  the  seat  of  former  gummata,  less  plentiful 
elsewhere.  As  the  liver-tissue  disappears,  the  parts  that 
remain  hypertrophy  and  regenerate,  so  that  the  islands  of 
liver-tissue  soon  increase  in  size  and  produce  lumpy  ex- 
crescences on  the  surface,  enlarged  lobules  on  the  cut  sur- 
face, or  enlargement  of  an  entire  lobe.  Thus  we  have 
seen  the  left  lobe  hypertrophied  to  the  normal  size  of  the 
right,  when  the  latter  had  become  atrophied  as  a  result  of 
syphilitic  disease. 

In  addition,  peritoneal  adhesions  and  distortions  of  the 
organ  or  of  the  gall-bladder  and  larger  bile-ducts  occur, 
and,  with  the  interference  to  the  portal  circulation  caused 
by  the  tumors  and  the  overgrowth  of  connective  tissue, 
add  to  the  many  disturbances  which  we  observe  in  the 
living  subject. 

Pancreas. — Although  the  pancreas  is  very  often  dis- 
eased in  the  hereditary  form  of  syphilis,  the  organ  usually 
escapes  in  the  ac(|uircd  form  in  adults.  Occasionally  gum- 
matous disease  and  alterations  produced  by  disease  of  the 
vessels  have  been  observed,  but  the  cases  are  extremely 
rare,  and  the  condition  cannot  be  determined  in  vivo  ex- 
cept by  inference,  when  gummatous  processes  are  present 
in  other  situations  at  the  same  time. 


TERTIARY  SYPHILIS.  49 

The  Respiratory  Tract. 

The  Nasal  Cavity. — In  the  secondary  period  the 
mucous  membrane  of  the  nasal  cavity  is  less  commonly 
affected  than  is  that  of  the  oral  cavity.  The  late  lesions, 
on  the  contrary,  are  quite  common  and  are  of  great  prac- 
tical significance.  The  most  frequent  seat  of  gummatous 
ulcers  is  the  septum,  especially  the  junction  between  the 
cartilaginous  and  bony  portions.  It  scarcely  needs  to  be 
said  that  the  jjeriosteum  and  investing  mucous  membrane 
rapidly  break  down  and  ulcerate.  Before  loug  the  cartil- 
age softens,  the  bone  becomes  carious,  and  perforation  of 
the  septum  results.  Such  a  perforation  is  sometimes  dis- 
covered by  the  physician  before  the  patient  himself  is 
aware  of  it.  The  secretion  is  purulent  and  mixed  with 
blood,  and  has  a  most  offensive  odor ;  often  it  dries  in  the 
nose  and  forms  brownish  crusts  which  conceal  the  floor 
of  the  ulcer  and  the  necrotic  portions  of  the  bone.  The 
necrosis  spreads  along  the  line  of  the  bony  septum  to 
the  hard  palate  and  a  perforation  of  the  bony  plate  of  the 
palate  results.  The  adjacent  bones,  the  superior  maxil- 
lary, the  ethmoid,  the  internal  pterygoid  plates  of  the 
sphenoid,  and  the  lachrymal  bones  may  also  be  involved. 

While  ulceration  and  suppuration  are  going  on,  the 
sense  of  smell  is  entirely  lost,  and  is  seldom  regained 
even  if  a  cure  is  effected.  Destruction  of  the  cartilagin- 
ous septum  results  in  the  saddle-nose ;  destruction  of  the 
vomer  and  of  the  nasal  bones  produces  sinking  of  the 
entire  nose.  It  is  often  possible  to  save  the  skin  of  the 
nose  even  when  there  has  been  extensive  destruction 
within  the  nasal  fossa,  but  in  time  it  withers  and  shrinks 
to  a  shapeless  stump,  nor  is  any  plastic  operation  possible. 
In  badlv  neglected  cases  the  entire  nose,  includino;  the 
skin,  may  be  destroyed. 

From  the  nasal  fossse  the  ulceration  spreads  to  the 
upper  lip,  the  alse  of  the  nose,  the  lachryuial  gland,  the 
posterior  nares,  and  even  as  far  as  the  head  of  the 
pharynx. 


50  SYPHILTS. 

P^ven  after  the  proce.ss  has  healed,  there  is  danger  of 
the  scars  in  the  nasal  cavity  reopening,  and  constant  care 
is  necessary  to  prevent  a  recurrence  of  the  disease. 

In  the  larynx  the  mucous  niemhrane  early  (in  the 
secondary  })eriod)  siiows  signs  of  the  disease;  in  the  form 
of  papules,  ulcers,  and  vegetations.  The  a[)pcarance  of 
gummata  in  this  important  organ  in  the  tertiary  period  is 
of  the  most  vital  significance  to  the  patient.  They  are 
counted  among  the  dangerous  forms  of  syphilis,  as  the 
rapid  disintegration  endangers  the  cartilages  of  the  larynx, 
the  epiglottis,  and  the  muscles  and  vocal  cords  with  the 
mucous  membrane  covering  them.  It  is,  therefore,  of 
the  greatest  importance  to  warn  the  patient  of  his  danger, 
so  that  he  may  subject  himself  to  the  necessary  treatment 
as  early  as  possible.  In  themselves  the  gummata  do  not 
differ  from  those  found  in  other  nuicous  membranes, 
being  characterized  by  the  same  tendency  to  rapid  de- 
generation. 

Infiltrations  and  ulcerations  in  the  trachea  and  in  the 
bronclii  often  follow  syphilis  of  the  larynx.  The  pro- 
cess may  also  begin  in  the  mediastinum  and  involve  these 
structures  secondarily.  The  gravity  of  the  symptoms 
depends  on  the  extent  and  depth  of  the  ulcerative  pro- 
cess ;  very  troublesome  after-effects  may  remain  even 
after  a  cure  is  effected. 

I/Ung- disease  in  ac(juired  syphilis  is  one  of  the 
rarer  occurrences,  esijecially  if  we  exclude  the  cases  whicli 
result  from  obstinate  disease  of  the  larynx  and  trachea. 
Cicatricial  hyperplasia  of  lung-tissue  and  peribronchitis, 
associated  with  gunmiata,  have  been  observed  at  autopsies. 
I  have  never  been  able  to  convince  myself  of  the  correct- 
ness of  these  anatomical  changes  by  my  own  experience. 
Glandular  tumors  in  the  mediastinum  may  exert  pressure 
on  the  bronchi  and  produce  |)eribronchitis  by  contiguity. 
If  the  parietal  layer  of  the  pleura  or  the  viscera  are  in- 
volved, we  may  have  periostitis  or  necrosis  of  the  ribs, 
and  adhesions. 


TERTIARY  SYPHILIS.  51 

Syphilis  of  the  Circulatory  System. 

Although  the  doctrine  of  syphilitic  disease  of  the  organs 
of  circulation  is  one  of  the  more  recent  achievements  of 
morbid  anatomy,  more  and  more  facts  are  being  daily 
collected  to  show  that  it  has  received  too  little  attention 
in  the  consideration  of  syphilitic  products. 

The  heart  presents  many  pathological  alterations  after 
syphilis.  We  distinguish  three  divisions :  syphilitic 
changes  in  the  smaller  vessels  of  the  heart,  the  products 
of  syphilis  in  the  pericardium  and  endocardium,  and 
finally  in  the  myocardium  itself.  Not  to  exceed  unduly 
the  limits  of  this  sketch,  we  shall  merely  mention  the 
most  important  alterations  and  the  clinical  phenomena  to 
which  thev  jjive  rise.^ 

All  the  syphilitic  affections  of  the  heart  that  have  been 
observed  belong  to  the  tertiary  period  ;  those  observed  in 
the  secondary  period  have  no  anatomical  foundation  and 
must  be  regarded  as  functional  disturbances. 

Fibrous  myocarditis  is  characterized  by  increase  in  the 
connective  tissue  and  by  the  formation  of  wheals,  and 
secondarily  by  atrophy  and  wasting  of  the  muscle-sub- 
stance. It  is  found,  in  limited  areas,  distributed  over  the 
interventricular  septum  and  in  the  walls  of  the  ventricles 
and  auricles. 

The  gummata  in  the  myocardium  produce  nodes  of 
varying  size,  showing  fatty  or  cheesy  degeneration  at  the 
center  and  surrounded  by  layers  of  fibrous  connective 
tissue.  Like  all  gummata,  they  may  remain  in  this  con- 
dition for  a  long  time,  or  they  may  break  down  and  pro- 
duce more  or  less  destruction  and  loosening  of  the  papil- 
lary muscles  and  valves. 

Syphilitic  endocarditis  and  pericarditis  are  usually  but 
accompanying  processes  of  disease  of  the  myocardium. 

In  making  a  diagnosis  in  vivo  it  is  to  be  remembered 
that   the    syphilitic    symptoms    appear   most   frequently 

^  For  further  details  on  "Syphilis  of  the  Heart,"  see  Archiv.  Jiir 
Dermatologie  und  Syphilis,  93. 


5'J  SYPHILIS. 

between  the  ages  of  thirty  and  forty,  associated  with,  or 
following  upon  the  later  lesions  of  syphilis.  At  a  more 
advanced  age  disease  of  the  heart  is  usually  due  to  athero- 
matous change  or  to  rheumatic  endocarditis,  or  to  fatty  or 
fibroid  degeneration,  as,  for  instance,  in  chronic  alcohol- 
ism, so  that  the  diagnosis  is  extremely  difficult.  It  is  to 
be  remembered  also  that  grave  functional  disturbances  of 
the  heart  may  be  simulated  by  syphilitic  products  in  the 
central  nervous  system,  as,  for  instance,  in  the  bulb. 

In  disease  of  the  heart-muscle  manifesting  itself  in 
angina,  palpitation,  and  severe  dyspnea,  it  is  easy  to 
demonstrate  the  objective  symptoms  of  dilatation,  asys- 
toly,  arrhythmia,  cyanosis,  and  slight  anasarca.  Other  pro- 
cesses in  the  region  of  the  valves  may  produce  the  symp- 
toms of  valvular  insufficiency.  Syphilitic  endarteritis  of 
one  of  the  coronary  arteries  may  give  rise  to  the  most 
intense  symptoms  of  angina  pectoris.  For  the  benefit  of 
the  practitioner  we  repeat  and  emphasize  the  rule  laid 
down  by  Scmola  :  "  If  a  patient,  who  has  unquestionably 
had  syphilis,  presents  himself  with  symptoms  of  a  per- 
sistent arrhythmia,  which  refuse  to  yield  to  hygienic  or 
pharmaceutical  remedies,  the  physician  must  conclude 
that  a  syphilitic  process  exists,  and  must  order  specific 
treatment  for  the  patient,  even  if  at  the  time  there  are  no 
symptoms  which  furnish  ocular  proof  of  the  presence  of 
constitutional  syphilis." 

Most  cases  of  heart-syphilis  are  discovered  accident- 
ally at  the  autopsy.  Death  usually  occurs  rapidly  and 
unexpectedly ;  rarely  death  is  preceded  by  exhaustion  of 
the  degenerated  myocardium  with  symptoms  of  cardiac 
weakness. 

Although  we  are  unable  to  diagnose  syphilitic  cardiac 
disease  with  certainty  in  the  living  subject,  yet  it  is  the 
duty  of  the  physician,  as  stated  in  Semola's  proposition 
quoted  above,  to  fight  the  disease  with  iodids  and  even 
^vith  mercury  in  doubtful  cases,  using  the  proper  precau- 
tions, as  the  disease  is  always  dangerous  and  almost  certain 
to  end  fatally. 


TERTIARY  SYPHILIS.  53 

In  arteries  of  medium  caliber  Heubner  has  de- 
scribed a  specific  affection  which  proceeds  cliiefly  from 
the  greatly  hypertrophied  intinia ;  it  is  known  as  endar- 
teritis obliterans.  All  the  layers  are  affected ;  in  some 
cases  cheesy  degeneration  develojjs  and  destroys  the  ad- 
ventitia  and  media,  so  tiiat  we  are  justified  in  speaking  of 
gummatous  arteritis.  It  occurs  most  frequently  and  in  its 
most  typical  form  in  the  arteries  at  the  base  of  the  brain ; 
it  has,  however,  also  been  observed  in  the  carotid,  the 
popliteal,  the  renal,  and  the  splenic  arteries,  and  in  periph- 
eral branches.  The  consequences  are  atrophy  and 
necrosis  of  the  organ  (spleen) ;  also  encephalomalacia, 
to  which  we  shall  return  later. 

The  etiology  of  thickened  valves  and  endo-aoHitis  is  more 
obscure,  as  these  structures  are  so  frequently  the  seat  of 
general  atheromatous  changes  ;  the  same  is  true  of  the 
sequelae,  especially  of  aneurysms,  and  we  take  occasion  to 
emphasize  the  fact  that  aneurysms  never  form  in  the  cere- 
bral cranial  arteries  in  the  typical  form  of  the  disease. 

The  smallest  arterial  branches  are  sometimes  found  to 
be  involved  in  the  late  forms  of  syphilis ;  trophic  disturb- 
ances and  overgrowth  of  the  connective  tissue  are  the 
result. 

The  veins  are  rarely  the  seat  of  syphilitic  products, 
although  gummata  have  been  described  in  the  jugular  and 
in  the  sheath  of  the  femoral. 

5yphilis  of  the  Genito-urinary  Apparatus. 

Kidney. — The  observations  of  the  last  few  years  have 
shown  to  what  extent  the  kidneys  may  be  affected  by  the 
syphilitic  process.  The  presence  of  albumin  in  the  kid- 
neys of  a  sy])hilitic  patient  is  not  in  itself  enough  to 
warrant  a  diagnosis  of  syphilitic  disease  of  the  kidneys. 
When  mercury  is  given  in  the  early  stage  of  syphilis,  the 
excretion  of  the  mercury  sets  up  an  irritation  in  the  kid- 
ney, and  considerable  quantities  of  albumin  are  found  in 
the  urine.     Amyloid  disease  is  found  in  the  kidneys  of 


54  SYPHILIS. 

cachectic  individuals  in  the  lute  stages  of  syphilis.  These 
conditions  make  it  difficult  to  determine  whether  the  kid- 
neys are  directly  concerned  in  the  syphilitic  process. 
Even  in  syphilitic  subjects  a  nephritis  based  on  diffuse 
interstitial  proliferation  is  considered  to  be  sufficiently 
accounted  for  on  anatomical  grounds.  Still,  gummatous 
tumors  have  been  found  accidentally  at  autopsies.  It  is 
not  likely,  however,  that  their  presence  would  even  be 
suspected  on  clinical  grounds,  nnless  perhaps  antisyphi- 
litic  treatment  were  found  to  be  followed  by  a  good  result 
in  a  case  of  violent  renal  symptoms  pointing  to  degenera- 
tion of  the  parenchyma. 

In  the  bladder  ulcers  have  often  been  observed  which 
were  thought  to  be  due  to  syphilis. 

The  testicles  are  much  more  frequently  attacked  by 
syphilis  than  is  generally  conceded.  The  disposition  of 
this  gland  to  specific  disease  may  be  explained  on  anatom- 
ical grounds,  or  by  its  liability  to  injury,  or  by  previous 
disease.  A  slight  infiltration,  involving  only  the  paren- 
chyma, is  not  demonstrable,  as  the  alteration  produced  is 
not  severe  enougli  to  cause  the  patient  to  consult  a  doctor. 
In  a  few  instances  I  have  been  able  to  determine  an  in- 
duration in  parts  of  one  or  the  other  testicle  in  men  who 
were  given  to  observe  themselves  anxiously,  or  who,  being 
on  the  point  of  marrying,  wished  to  be  examined  for 
possible  remains  of  syphilitic  disease,  or  even  Avere 
reminded  of  a  former  attack  of  the  disease  by  the  birth 
of  children  with  hereditary  syphilis.  In  two  cases  which 
I  had  known  before  the  disease  occurred  I  was  able  to 
demonstrate  an  induration  in  the  tail  (globus  minor) 
of  the  epididymis. 

Two  forms  are  usually  distinguished,  /i6)'ows  and.  gum- 
matous orchitis.  Both  belong  to  the  late  forms  and  de- 
velop two  years  or  more  after  the  infection. 

Fibrous  orchitis  is  more  frequent  and  occurs  earlier 
than  the  gummy  form.  It  begins  with  an  infiltration  in 
the  septum  of  the  scrotum  whicli  spreads  until  it  pene- 
trates the  parenchyma;  the  head  (globus  major)  of  the 


TERTIARY  SYPHILIS.  55 

epididymis  soon  becomes  involved.  The  patient  feels  no 
pain,  only  a  sense  of  increased  weight  and  traction  in  the 
testicle ;  the  organ  is  fonnd  to  be  enlarged  and  harder 
than  normal.  If  the  process  goes  on,  the  body  of  the 
other  testis  is  included  in  the  tumor,  which  increases  more 
and  more  in  size.  The  patient  complains  of  dragging 
pains  as  high  up  as  the  inguinal  canal. 

\yith  potassium-iodid  treatment  the  sym})toms  often 
disappear  within  a  few  days;  but  if  the  condition  lasts, 
strands  of  connective  tissue  develop  within  the  paren- 
chyma of  the  organ  which  atrophies  in  ])arts  and  becomes 
permanently  indurated. 

Gummatous  orchitis  is  distinguished  by  the  apj)earance 
of  a  node,  which  gradually  increases  in  si/e  and  becomes 
adherent  to  the  investing  membranes.  The  tumor  is 
movable ;  if  it  breaks  down,  it  bursts  toward  the  exterior, 
and  a  brownish  material,  consisting  of  detritus  and  thin, 
watery  pus,  is  discharged.  In  cases  of  long  standing 
there  is  usually  more  than  one  node ;  the  substance  be- 
tween the  nodes  atroi)hies  from  pressure,  and  what  remains 
becomes  hard  from   overgrowth  of  the  connective  tissue. 

Tlie  tunica  vaginalis  propria  also  becomes  involved  in 
disease  of  the  testis ;  the  writer  has  often  seen  it  hyper- 
trophied  and  filled  with  a  serous  exudate.  The  scrotum 
may  swell  to  the  size  of  the  fist  or  even  the  head  of  an 
infant ;  the  tumor  is  excessively  tense,  so  that  it  is  im- 
possible to  distinguish  the  different  parts  of  the  organ  by 
palpation.  The  closely  adherent  skin  over  a  tumor  of 
this  kind  may  be  destroyed  in  places.  But,  instead  of  a 
discharge  of  liquid  products  of  degeneration,  it  is  more 
common  to  have  a  solid  mass  of  yellowish-white,  fiitty  or 
cheesy  material  appear  through  the  o[)ening.  If  the  pro- 
cess has  gone  as  far  as  this,  there  is  no  hope  of  recovery, 
and  amputation  is  the  oidy  relief. 

The  penis,  especially  the  glans,  the  coronary  sulcus, 
and  the  prepuce,  is  often  the  seat  of  a  gummatous  pro- 
cess which  must  be  distinguished  not  only  from  non- 
syphilitic  tumors,  but  also  from  initial  forms  of  syphilis 


56  SYPHILIS. 

(initial  sclerosis).  The  gumma  is  much  more  prone  to 
rapid  decay  than  is  the  sclerosis ;  hence  it  is  very  impor- 
tant to  recognize  a  gumma  as  early  as  possible  so  as  to 
begin  the  proper  -treatment  at  once.  The  condition  of 
the  inguinal  glands  is  of  vital  significance,  since  they  do 
not  become  swollen  in  gummatous  disease ;  in  addition, 
anamnesis,  duration,  and  course  must  be  carefully  taken 
into  account.  Gummata  beginning  in  the  coronary  sul- 
cus are  very  prone  to  spread  to  the  glans  and  often  destroy 
it  in  a  very  short  time.  A  gumma  situated  near  the 
urethra  is  dangerous  on  account  of  its  tendency  to  pene- 
trate into  the  corpus  cavernosum. 

Gummata  in  the  skin  of  the  penis  are  equally  danger- 
ous, not  only  because  they  destroy  the  skin  and  lead  to 
external  scar-formation,  but  chiefly  because  they  spread 
to  tlie  corpus  cavernosum.  Occasionally  the  gumma 
starts  in  the  corpus  cavernosum  itself.  But  in  whatever 
manner  the  gumma  may  attack  the  corpus  cavernosum, 
the  infiltrate  is  sure  to  penetrate  deeply  and,  after  a  cure 
by  absorption  has  been  effected,  to  leave  cicatricial  con- 
tractions. The  consequence  is  that  the  corpus  cavernosum 
is  imperfectly  filled  with  blood,  and  there  is  usually  a 
bend  in  the  penis  at  this  spot  during  erection,  or,  if  the 
destruction  has  been  very  extensive,  erection  is  incom- 
plete or  even  impossible. 

In  the  female  genitals  the  vulva,  and  in  more  ad- 
vanced cases  the  vagina,  are  the  most  common  seats  of 
the  process.  Even  under  favorable  conditions  deformi- 
ties, cicatricial  contractions,  and  stenoses  result ;  but  if 
the  process  })enetrates  more  deeply,  it  often  produces  per- 
forations into  the  rectum.  Usually  a  thorough  and  pro- 
tracted course  of  treatment  is  necessary  to  arrest  the 
ulceration,  after  which  operative  interference  may  be  re- 
sorted to.  If  we  at  last  succeed  in  arresting  the  process,  the 
most  we  can  hope  to  accomplish  l)y  an  operation  is  to 
relieve  to  some  extent  the  discomfort  with  which  the  con- 
dition is  attended. 

Uterus. — Syphilis  may  invade  the  uterus  by  direct  in- 


TERTIARY  SYPHILIS.  57 

fection  through  the  os  (Plates  6a,  6b,  7).  The  resulting 
sclerosis  is  followed  by  extensive  infiltration  and  over- 
growth of  connective  tissue  at  the  cervix,  which  may 
under  certain  conditions  interfere  with  parturition. 

Papules  may  also  appear  on  the  mucous  membrane  of  the 
vaginal  orifice  (PI.  39).  They-  are  usually  associated  with 
papules  on  the  external  genitals  and  disappear  with  them 
under  proper  treatment.  We  may  also  mention  the  in- 
crease in  size  and  density  of  the  uterine  tissue  which  is 
occasionally  found  in  syphilitic  parturient  women.  I 
have  often  seen  labor  interrupted  by  uterine  hemorrhages, 
etc.,  in  such  cases,  wliich  usually  ended  in  imperfect  invo- 
lution of  the  uterus. 

Gummatous  neoplasms  have  also  been  found  in  the 
uterine  tissue,  but  they  are  no  doubt  extremely  rare. 

Gummatous  processes  occur  in  the  matainse  in  the 
later  stages  of  syphilis  ;  they  usually  proceed  from  the 
subcutaneous  tissue  and,  by  spreading  to  the  mammary 
gland,  produce  the  picture  of  a  mastitis  (Plates  48a,  48b). 
The  skin  over  these  infiltrations  in  the  tissue  of  the 
gland  is  usually  destroyed,  and  deeper  parts  may  be  lost 
if  the  proper  treatment  is  not  at  once  resorted  to.  I 
have  known  masses  as  large  as  a  pigeon's  egg  to  be  de- 
stroyed in  rapidly  spreading  infiltrations  and  serpiginous 
ulcers  of  the  skin  and  subcutaneous  cellular  tissue  in 
neglected  cases.  Potassium  iodid  is  a  valuable  remedy  in 
disease  of  this  organ,  as  it  is  in  disease  of  the  testicle ;  its 
favorable  influence  on  the  process  is  manifest  after  a 
few  days,  and  it  may  serve  to  clear  up  a  doubtful  diag- 
nosis. 

Syphilis  of  the  Eye. 

The  specialist  in  venereal  diseases  sees  principally  dis- 
eases of  the  orbits,  the  eyelids,  the  cornea,  the  sclerotic, 
and  the  iris,  as  deeper-lying  diseases  of  the  organ  and 
paralyses  are  usually  taken  to  the  oculist.  We  shall, 
therefore,  in  accordance  with  the  plan  we  have  adopted, 
confine  ourselves  to  a  short  review  of  these  affections. 


58  SYPHILIS. 

Most  forms  of  syphilis  of  the  orbit  occur  as  a  peri- 
ostitis, eitiicr  localized  in  the  orbital  margin  from  the  be- 
ginning or  extending  from  the  frontal  bono  to  the  orbital 
margin.  We  distinguish  two  forms :  productive  and 
destructive  periostitis,  both  due  to  a  gummatous  process. 
The  hypertrophic  forms  often  begin  in  the  secondary 
period,  and  are  to  be  distinguished  from  hyperostoses  of 
the  orbits,  as  they  are  attended  with  considerable  deposi- 
tions on  the  orbital  margin.  The  gumma  attacks  the 
skin  as  well  as  the  bone,  and  may  eventually  perforate 
externally  if  it  is  not  absorbed.  The  eyelid  becomes 
edematous  and  remains  immoveable  in  a  drooping  position. 
If  the  levator  pal})ebr8e  remains  inactive  for  a  long  time, 
there  is  danger  of  the  ptosis  becoming  permanent.  If 
the  destruction  of  the  skin  and  eyelid  is  extensive,  cica- 
tricial contractions,  ectropion,  and  lago})hthalmos   result. 

The  bones  are  more  subject  to  gummy  periostitis  than 
to  the  hyperplastic  form.  A  swelling  in  the  periosteum 
and  infiltration  of  the  cellular  tissue  of  the  orbit  may  simu- 
late an  orbital  tumor,  as  the  same  sym])toms  occur  in  both 
conditions.  The  upper  wall  is  most  frequently  attacked, 
more  rarely  the  thin,  internal  Avail,  the  ethmoid  bone. 
The  disease  is  heralded  by  neuralgia  and  headache,  becom- 
ing worse  in  the  evening  and  at  night ;  the  pain  is  in- 
creased by  touching  the  orbital  margin.  A  characteristic 
symptom  is  dislocation  of  the  globe,  as  it  is  a  certain  sign 
of  infiltration  in  the  periosteum  and  cellular  tissue.  If 
the  periostitis  is  seated  in  front,  the  eyeball  will  be  dis- 
placed laterally  ;  if  at  the  bottom  of  the  orbit,  it  will 
protrude  forward  (protrusio  bulbi).  Syphilitic  tumors 
are  large,  so  that  there  is  usually  exophthalmos  in  addi- 
tion to  lateral  dis])Iacement.  A  very  characteristic  phe- 
nomenon in  syphilitic  periostitis  is  interference  with  move- 
ment of  the  globe  in  one  or  more  directions,  even  when 
the  muscles  are  intact,  showing  that  it  is  entirely  due  to 
dislocation  of  the  globe.  Eventually  the  muscles  also 
become  involved,  and  temporary  or  permanent  loss  of 
power  results.     If  taken  in  time,  the  ulcers  can  often  be 


TERTIARY  SYPHILIS.  59 

cured ;  but  if  the  infiltrate  liquefies,  the  ulcer  breaks 
through  the  anterior  surface,  usually  at  the  orbital  mar- 
gin, even  when  the  bone  is  still  solid.  If  the  periostitis 
runs  on  to  necrosis,  perforations  into  the  nose  and  antrum 
of  Highmore  result ;  ])erforation  into  the  cranium  may 
produce  a  fatal  nieningiti.-:. 

The  skin  of  the  eyelids  is  often  attacked  in  pri- 
mary syphilitic  disease.  Later,  papules  may  appear  on 
the  palpebral  edges  and  on  the  conjunctivse.  Gummata 
produce  a  plate-like  infiltration,  and  the  conjunctiva 
assumes  the  appearance  of  trachoma  from  the  newly 
formed  granulations.  Syphilitic  tarsitis,  an  affection  of 
the  cartilage  of  the  eyelid,  has  also  been  observed  in  the 
gummatous  stage  (PI.  43b).  Gummy  processes  in  the 
lids  may  inv^olve  the  conjunctiva  and  cause  destruction  or 
mutilation  of  the  eyelid. 

Diseases  of  the  COmea  belong  to  hereditary  syphilis  ; 
they  take  the  form  of  interstitial  keratitis  and  are  usually 
associated  with  diseases  of  the  iris,  the  ciliary  body,  and 
the  sclerotic.  Gummata  have  been  observed  in  the 
sclerotic,  both  j)rimary  and  derived  from  the  uveal  tract, 
running  on  to  deo-eneration  and  ulceration. 

Iritis  is  frequent  in  the  secondary,  but  very  rare  in  the 
tertiary,  stage  of  syphilis.  Several  forms  are  distinguished. 
The  mildest  variety  is  probably  serous  iritis.  It  is  char- 
acterized by  photophobia,  moderate  ciliary  congestion,  a 
slight  discoloration  of  the  iris,  and  the  aj)pearance  of  a 
deposit  on  the  ])Osterior  wall  of  the  cornea.  The  pupil 
reacts  to  light,  and  the  deposit  often  has  the  form  of  a 
triangle  with  its  apex  pointing  upward.  In  the  second 
form,  plastic  iritis,  the  ciliary  congestion  is  greater,  the 
discoloration  of  the  iris  more  pronoiuiced,  its  markings 
indistinct,  the  tissue  more  spongy,  ])upillary  reaction 
almost  absent,  and  the  pujiillary  margin  of  the  anterior 
lens-capsule  held  fast  by  adhesions.  The  pupil  may  even 
be  covered  by  a  newly  formed  membrane  (pseudomem- 
brane).  Deposits  often  appear  on  the  posterior  wall  of 
the  cornea.     The   aqueous  humor  is  turbid,  and  on  the 


60  SYPHILIS. 

floor  of  the  anterior  chamber  there  is  sometimes  found  a 
hypopyon.  In  a  third  form,  papular  or  condylomatous 
iritis,  the  ciliary  margin  of  the  iris  is  studded  with  small, 
miliary  nodules,  which  spring  from  the  tissue  of  the  iris 
and  have  a  reddish-yellow  color  (PI.  43a).  In  this  form  the 
ciliary  congestion  and  the  posterior  adhesions  are  more 
marked  ;  the  other  symptoms  are  the  same  as  those  of 
plastic  iritis.  Unless  relief  is  speedily  obtained,  various 
troublesome  conditions  may  result — adhesions,  occlusion 
of  the  pupil,  and  other  grave  disturbances. 

We  pass  over  the  diseases  of  the  ciliary  body,  the 
choroid,  the  vitreous  body,  the  retina,  and  of  the  oi)tic 
nerve,  as  they  belong  to  the  special  province  of  ophtlial- 
mology  both  as  regards  diagnosis  and  treatment. 

Syphilis  of  the  Central  Nervous  System. 

Syphilis  of  the  Brain. — Syphilis  of  the  central 
nervous  system  manifests  itself  in  such  a  multiplicity 
of  forms  and  gives  rise  to  such  a  vast  number  of  symp- 
toms that  it  is  difficult  to  distinguish  it  from  other  nervous 
diseases.  There  is  hardly  a  symptom  in  the  entire 
pathology  of  the  nervous  system  that  may  not  be  pro- 
duced by  syphilis.  A  diagnosis  of  syphilitic  nervous 
disease  must  tiierefore  be  based  on  a  definite  history,  or  on 
the  existence  of  other  processes  combined  with  the  ner- 
vous lesion  that  are  positively  known  to  be  specific  in 
character.  Generally  speaking,  syphilitic  nervous  diseases 
belong  to  the  late  forms  of  syphilis,  the  majority  appear- 
ing from  the  fifth  to  the  tenth  year  after  the  disease  has 
been  acquired.  In  order  to  get  a  general  idea  of  this  ex- 
tensive group  of  diseases  we  must  bear  in  mind  that  the 
processes  which  eventually  attack  the  nerve-substance, 
and  either  partially  or  wholly  destroy  it,  may  originate  in 
various  ways.  Destructive  processes  in  the  bones  extend 
to  the  dura  and  meninges  and  thence  to  the  brain  itself. 
Conversely,  gummata  in  the  dura  produce  pathological 
changes  in  the  bone  and  in  the  meninges.     Gummatous 


TERTIARY  SYPHILIS.  61 

or  chronic  inflammatory  processes  may  originate  in  the 
softer  membmnes,  the  arachnoid  and  the  pia,  and  invade 
the  brain  secondarily.  Lastly,  arterial  disease  is  the 
commonest  canse  of  pathological  alterations  in  the  nerve- 
substiince  itself.  The  various  symptoms  which  we  observe 
consecutively  in  the  living  subject  depend  upon  the  seat 
and  extent  of  the  partial  or  total  destruction  of  nervous 
tissue  by  the  processes  mentioned. 

Syphilitic  Diseases  of  the  Periphery  of  the 
Brain. — Chronic,  exudative,  fibrous,  hyperplastic  in- 
flammation of  the  meninges  rarely  occurs  alone,  being 
usually  combined  with  gumraata.  The  gummy  deposi- 
tions are  found  chiefly  in  the  neighborhood  of  the  cerebral 
arteries  and  nerves ;  the  cranial  nerves  at  their  exit  are 
enclosed  in  the  masses  of  exudate  in  the  subarachnoid 
space.  The  diffuse,  fibrous  neoplasms  spread  out  over 
larger  or  smaller  areas  and  produce  adhesions  of  the 
meninges  to  each  other  and  to  the  surface  of  the  brain, 
so  that  several  dry,  cheesy  gummatous  foci  may  become 
enclosed.  Fibrous  as  well  as  gummatous  neoplasms  ex- 
tend to  the  cortex  or  even  to  the  white  matter.  The 
cranial  nerves  which  become  involved  in  this  process  at 
the  base  of  the  brain  arc  :  the  0])tic  chiasm,  oculomotor, 
trochlear,  abducent,  trigeminal,  facial,  glossopharyngeal, 
vagus,  spinal  accessory,  and  hypoglossal. 

Gummata  arising  in  the  brain-substance  itself  often 
attain  to  a  considerable  size  and,  according  to  their  seat, 
produce  phenomena  similar  to  those  produced  by  other 
neoplasms.  Such  a  gummatous  encephalitis  may  be 
widely  distributed  over  the  cortex,  the  white  matter, 
and  the  base  of  the  brain  without  involving  the  meninges. 

The  diseases  of  the  cerebral  arteries  are  of  the 
greatest  importance ;  we  have  already  made  their  ac- 
quaintance under  the  name  of  syphilitic  endarteritis. 
They  are  more  or  less  significant,  according  as  the 
branches  involved  are  end-vessels  or  not.  The  occlusion 
of  the  cerebral  vessels  which  ensues  is  followed  by  nutri- 
tive disturbances  in  the   brain-substance,  softening,  and 


62  SYPHILIS. 

destructive  hemorrhages  of  greater  or  lesser  intensity. 
Areas  of  softening  or  necrosis  of  the  brain  develop,  such 
as  we  find,  for  instance,  in  the  basal  ganglia,  the  pons,  and 
medulla  oblongata,  or  there  may  be  no  more  than  a  state 
of  impaired  nutrition,  as  there  is  a  possibility  of  collateral 
circulation  being  established. 

As  we  have  intimated  above,  these  anatomical  altera- 
tions alluded  to  give  rise  to  a  very  great  variety  of  symp- 
toms. The  most  important  for  the  estimation  of  the 
gravity  of  the  disease  are  headache,  insomnia,  vertigo, 
disturbance  of  consciousness  and  intelligence,  etc. 

Depending  upon  the  position  of  the  morbid  focus,  be  it 
a  gumma  or  an  encephalomalacia,  there  will  be  paralyses 
and  disturbances  of  sensibility. 

The  psychical  disturbances  M'hich  frequently  accompany 
the  conditions  referred  to  have  no  definite  anatomical 
foundation  ;  they  are  caused  by  the  grave  nutritive  dis- 
turbances in  the  brain  either  from  the  general  cachexia  or 
from  a  local  process. 

Diseases  of  the  cortex  may  be  produced  by  gum- 
matous infiltrations  or  by  enccphalomalacial  processes 
following  the  occlusion  of  a  main  artery  (for  instance, 
the  middle  cerebral  artery),  in  which  case  the  motor 
centers  (the  facial  nerve),  the  centers  of  speech  and  of 
sensibility,  as  well  as  the  intellectual  centers,  may  be 
seriously  injured.  The  paralysis  may  attack  several 
groups  of  muscles  in  succession,  or  involve  the  entire 
extremity  from  the  start.  Sometimes  cortical  epilepsy 
occurs,  showing  itself  in  tonic  and  clonic  spasms  of  single 
muscle-groups,  or  in  epileptic  convulsions  affecting  the 
entire  half  of  the  body.  The  epilepsy  is  attended  with 
loss  of  consciousness.  Temporary  aphasia  is  usually 
present  in  cortical  syphilis. 

Cerebellum. — The  diseases  of  the  cerebrum  which 
have  been  mentioned  may  under  similar  conditions  affect 
the  cerebellum  also.  In  this  situation  they  produce  dis- 
turbances of  the  equilibrium,  and  are  often  combined 
with  violent  headache,  vertigo,  and  pressure-sensations. 


TERTIARY  SYPHILIS.  63 

Althougli  syphilitic  processes  in  the  brain  present  sub- 
stantially the  same  symptoms  as  other  cerebral  diseases, 
there  are  certain  combinations  that  are  typical  of  specific 
disease  and  constitute  a  characteristic  symptom-complex  : 
this  is  the  case  in  syphilis  of  the  base  of  the  brain. 
If  the  bones  through  which  the  cranial  nerves  pass  are 
diseased,  the  nerves  themselves  become  involved.  The 
gummatous  process  attacks  the  jjerineurilemma  and  de- 
stroys the  nerve-elements.  Hence  the  chief  consequence 
of  disease  of  the  base  is  the  paralysis  observed  in  these 
nerves,  particularly  tiie  ocular  nerves. 

Gummatous  diseases  of  the  meninges  which  affect  the 
pons  or  the  peduncle  of  the  cerebellum  and  produce 
paralysis  on  the  side  of  the  body  opposite  to  the  seat  of 
the  lesion  are  also  accompanied  by  paralyses  of  the  same 
side ;  this  often  happens  in  the  case  of  the  oculomotor,  the 
abducent,  and  the  facial. 

Syphilitic  disease  of  the  arteries  at  the  base  of  the 
brain,  which  we  mentioned  above,  and  gummata  in  the 
same  situation  are  followed  by  very  complicated  phe- 
nomena, being  characterized  by  paralyses  in  the  peripheral 
distribution  of  the  cranial  nerves.  In  all  cases  of  exten- 
sive gunmiata  or  foci  of  softening  various  nerve-paralyses 
are  always  associated  with  peripheral  i)aralyses.  It  there- 
fore becomes  necessary  to  determine  whether  they  are  due 
to  nerve-lesions  within  or  without  the  brain-substance. 

Syphilitic  disease  of  the  spinal  cord,  whether 
primary  or  secondary  to  disease  of  the  meninges,  is 
characterized  by  the  occurrence  of  limited  gummatous 
areas  or  by  fibroid  change  in  the  meninges.  Thus  the 
myelomalacia  may  attack  only  peripheral  portions  of  the 
white  matter,  or  it  may  involve  the  gray  matter  as  well. 
The  resulting  clinical  pictures  of  myelomeningitis  and 
myelitis  present  many  variations,  depending  upcm  the 
])articular  segment  or  number  of  segments  involved  ;  we 
shall  not  enter  into  a  detailed  descri})tion  of  them  at  this 
point. 

It  might  be  well  to  call  attention  to  a  certain  clinical 


64  SYPHILIS. 

picture  often  seen  in  syphilis,  a  kind  of  tabes  character- 
ized, usually,  by  the  absence  of  the  xVrgyll-Robertson 
pupil  ahd  optical  atrophy.  Such  cases  should  be  carefully 
watched  for  some  time  and  the  effect  of  antisyphilitic 
treatment  observed,  before  the  ])atient  is  promised  a-cure. 
As  regards  the  classic  form  of  tabes,  we  know  only  that  it 
often  develops  in  syphilitic  patients ;  we  have  as  yet  no 
knowledge  of  any  intimate  relation  existing  between  the 
two  processes. 

The  nerve-roots  and  the  cauda  equina  may  be 
attacked  by  secondary  (meningitis),  or  by  primary  (oculo- 
motor nerve)  neuritis. 

In  conclusion,  a  word  in  regard  to  various  neuroses  in 
the  peripheral  nerves  which  we  have  observed  in  the 
course  of  a  syphilitic  process. 

Such  neuroses  may  occur  in  the  distribution  of  the  tri- 
geminal or  of  the  facial,  or  in  peripheral  nerves  like  the 
ulnar  and  sciatic.  They  begin  with  sensory  disturbances 
which  soon  become  extremely  painful ;  later  there  may  be 
motor  and  even  trophic  disturbances.  The  prognosis  is 
good,  however,  and  we  have  often  been  able  to  effect  a  com- 
plete cure  by  antisyphilitic  treatment.  But  if  the  neuro- 
sis persists,  atrophy  and  loss  of  function  may  result. 

HEREDITARY   SYPHILIS. 

The  term  hereditary  or  congenital  syphilis  is  applied  to 
the  disease  when  the  fetal  organism  becomes  infected  in 
utero.  The  germ  may  become  infected  at  the  time  of 
impregnation  if  the  germ-cells  of  one  or  both  parents  are 
diseased  (so-called  germinal  infection),  or  the  offspring 
becomes  infected  during  its  development  in  utero  before 
birth.  While  it  is  impossible  to  formulate  definite  laws 
of  heredity,  w^e  submit  the  following  generally  accepted 
theories : 

1.  If  both  parents  are  syphilitic  before  conception,  the 
more  recent  their  own  infection  the  greater  the  danger  of 
infection  to  the  offspring.     The  power  of  transmission  in 


HEREDITARY  SYPHILIS.  65 

most  cases  decreases  from  about  the  fourth  year  after  in- 
fection, but  it  may  be  present  as  late  as  fourteen  or  fifteen 
years  after  that  event.  Syphilitic;  parents  may  produce 
syphilitic  children,  not  only  during  the  periods  when 
demonstrable  symptoms  are  present,  but  also  during  the 
intermission  periods. 

2.  The  most  frequent  infection  is  from  the  mother 
(ovular  infection).  Again,  the  duration  of  the  mother's 
syphilis  plays  an  important  role.  Recently  infected 
mothers,  with  few  exceptions,  always  infect  their  off- 
spring; if,  on  the  other  hand,  the  infection  is  of  longer 
standing,  a  relatively  healthy  child  is  occasionally  born 
between  two  syphilitic  children. 

3.  If  the  mother  is  infected  during  pregnancy,  the 
child  may  also  become  infected  in  utero  through  the 
placenta.  It  is  generally  held  that  the  placenta  must 
first  become  diseased  before  such  postconceptional  infection 
can  take  place. 

4.  According  to  many  observers,  a  syphilitic  father  is 
capable  of  infecting  his  offspring  with  syphilis  at  the  time 
of  impregnation  (spermatic  infection).  If  the  mother  has 
been  infected  at  the  same  time  by  her  syphilitic  husband, 
she  becomes  immune  through  gestation  of  the  syphilitic 
fetus;  she  can  nurse  her  diseased  child  without  incurring 
the  danger  of  becoming  infected  by  it  (Colles's  law).  Ex- 
ception has  been  taken  to  this  law  because  once  a  mother 
was  infected  by  her  syphilitic  child,  and  in  another  in- 
stance a  mother  who  had  given  birth  to  a  syphilitic  child 
was  infected  at  the  end  of  her  pregnancy. 

The  syphilis  of  the  parents,  especially  of  the  mother, 
has  such  different  effects  on  the  syphilis  of  the  offspring 
that  little  or  nothing  positive  can  be  said  concerning  its 
influence. 

If  both  parents,  and  especially  the  mother,  contract 
syphilis  shortly  before  conception  takes  place,  the  fetus 
soon  dies  iyi  utero  and  abortion  occurs  during  the  third  or 
fourth  month.  Various  factors  are  concerned  in  this 
result :  the  diseased  embryo  is  incapable  of  development, 


66  SYPHILIS. 

the  mother's  nutrition  is  so  mucli  iinpaired  by  licr  disease 
that  she  is  unable  to  nourish  the  fetus  properly,  the  uterus 
itself  may  be  diseased,  or  the  placenta  is  so  altered  by  the 
syphilitic  disease  of  the  blood-vessels  that  the  fetus  cannot 
be  nourished  and  therefore  dies. 

While  this  is  unfortunately  the  most  frequent  termina- 
tion of  such  pregnancies,  there  are  other  cases  in  which 
the  fetus  goes  on  developing  until  the  seventh  or  eighth 
month  and  is  then  born  prematurely,  a  sickly  child,  or  is 
stillborn  at  the  end  of  pregnancy.  Finally,  the  child 
may  be  born  alive,  but  with  such  grave  syphilitic  disease 
that  it  succumbs  in  a  few  hours  or  days.  Such  births 
occur  chiefly  when  the  parents  have  been  suffering  from 
syphilis  for  some  time  and  in  cases  where  the  virulence 
of  the  disease  has  been  reduced  by  palliative  treatment. 

Parents  in  the  gummatous  stage  of  syphilis  usually  pro- 
duce healthy  children.  The  author  has  known  many 
cases  of  comparatively  severe  tertiary  disease  on  the  part 
of  the  mother  during  pregnancy,  which  nevertheless 
terminated  favorably.  It  is  a  curious  and  hitherto  unex- 
plained fact  that  a  relatively  healthy  child,  practically 
free  from  specific  symptoms,  may  be  born  between  two 
diseased  children. 

It  follows  from  what  has  been  said  that  it  is  impossible, 
in  a  case  of  positive  syphilis  of  the  parents,  to  predict 
whether  the  offspring  will  be  healthy  or  diseased  ;  experi- 
ence, however,  teaches  that  careful  treatment  of  the  par- 
ents affords  the  best  guarantee  for  the  proper  development 
of  the  offspring. 

The  history  of  many  countries  which  have  been  visited 
by  epidemics  of  syphilis  shows  what  a  decimating  effect 
hereditary  syphilis  has  on  the  population.  To-day  the 
eloquence  of  figures  confirms  what  had  been  obtained  by 
induction  : 

Von  Wiederhofer  estimates  the  mortality  of  syphilitic 
infants  to  be  99  per  cent.  Fournier  has  constructed  the 
following  table  for  the  mortality  of  the  offspring  of  syph- 
ilitic parents  : 


HEREDITARY  SYPHILIS.  67 

When  both  parents  are  syphilitic,  68.5  per  cent. 
When  the  mother  is  syphilitic,  60.0  per  cent. 
When  the  father  is  syphilitic,         28.0  per  cent. 

Hereditary  syphilis  is  conveniently  divided  into  an 
early  (syphilis  hereditaria  prsecox),  and  a  late 
form  (syphilis  hereditaria  tarda). 

A  fetus  that  dies  early  rarely  exhibits  any  pathological 
changes.  In  stillborn  children  certain  pathological  altera- 
tions are  almost  constantly  found  in  many  organs ;  the 
most  important  of  these  are  osteochondritis  at  the  epiph- 
yses of  the  long  bones,  enlargement  of  liver  and  spleen, 
abscess  in  the  thymus  gland,  and  disease  of  the  heart 
and  blood-vessels  and  of  the  digestive  tract.  To  these 
are  added,  in  tlie  order  of  decreasing  frequency,  diseases 
of  the  nervous  tissues,  of  the  kidneys,  testicles,  etc.  It 
is  not  within  our  province  to  describe  these  important 
and  interesting  alterations  in  detail,  and  we  shall  merely 
mention  a  few  phenomena  of  practical  clinical  importance 
observed  in  hereditary  syphilis. 

One  absolutely  fatal  form  of  the  disease  sometimes 
declares  itself  at  birth ;  the  term  syi)hilis  haemor- 
rhagica  neonatorum  is  applied  to  it.  The  principal 
alterations  occur  in  the  blood-vessels  and  give  rise  to 
hemorrhages  into  the  parenchyma  of  organs,  particularly 
into  the  cellular  tissue  in  which  the  vessels  lie  embedded. 
Death  occurs  very  early,  in  the  first  few  hours  or  at  most 
within  two  days,  with  the  symptoms  of  cardiac  weakness, 
cyanosis,  sometimes  with  peripheral  edema,  anasarca,  or 
even  ascites.  The  many  hemorrhages  on  the  body  resem- 
ble small  petechiie;  sometimes  more  extensive  extravasa- 
tions are  found. 

The  principal  symptoms  observed  in  syphilitic  infants 
are  the  nutritive  disturbances  to  which  they  are  subjected 
while  still  in  utero.  The  body-weight  is  usually  below 
normal ;  the  skin  is  withered  and  hangs  in  folds.  Of  the 
diseases  which  present  visible  alterations  the  most  fre- 
quent is  the  so-called  Syphilitic  pemphigus,  which 


68  SYPHILIS. 

either  exists  at  birth  or  develops  within  the  first  three  or 
four  days.  The  vesicles  of  this  exanthema  are  collapsed 
and  either  burst  or  dry  up,  leaving  excoriations  or  sores 
covered  with  scabs  on  the  thin,  pale  skin  (PI,  58).  The 
internal  organs  of  such  children  are  always  diseased,  and 
they  pine  away  in  spite  of  the  most  careful  nursing. 
They  usually  die  of  inanition  in  one  or  two  weeks;  it  is 
rarely  possible  to  kec])  them  alive  longer  than  that. 

In  the  very  first  days  of  the  infant's  life  disease  of 
the  navel  plays  an  important  part ;  in  spite  of  the 
greatest  care  hemorrhages  and  ulcerative  processes  occur 
and  are  often  followed  l)y  general  septic  infection. 

Septic  infection  and  the  entrance  of  various  bacteria 
are  favored  not  only  by  the  umbilical  lesion,  but  also  by 
the  many  sores  on  the  skin  caused  by  the  exanthemata. 
Furunculosis,  long  held  to  be  a  syphilitic  product  in  the 
skin,  is  an  example.  All  these  adverse  conditions  com- 
bine to  bring  on  the  speedy  death  of  the  already  debili- 
tated infant. 

Another  very  frequent  disease  is  snuffles,  which  early 
declares  itself  in  syphilitic  infants.  The  mucous  mem- 
brane of  tiie  nose  becomes  swollen ;  dyspnea  is  the  most 
distressing  symptom,  the  excessive  secretion  being  of  sec- 
ondary importance.  The  infiltration  sj)reads  from  the 
mucous  membrane  to  the  perichondrium  and  periosteum, 
and  finally  results  in  the  formation  of  a  saddle-nose  (PI. 
60c). 

Before  long,  papular  eruptions  appear  on  the  nates  and 
about  the  genitals  at  the  junction  between  mucous  mem- 
brane and  skin.  The  papules  become  macerated  and 
form  ulcers  or  fissures  at  the  angles  of  the  mouth  and 
about  the  nostrils.  In  addition,  vcslcopustular  exanthe- 
mata appear  on  the  skin  which  soon  desiccate  and  leave 
brown  scabs. 

The  matrix  of  the  nails,  the  palms  of  the  hands,  and 
the  soles  of  the  feet  are  also  attacked  by  eruptions. 

Diseases  of  the  eyes,  such  as  iritis,  keratitis,  etc., 
occur ;  they  give  rise  to  pronounced  swelling  of  the  con- 


HEREDITARY  SYPHILIS.  69 

junctiva,  purulent  secretion  from  the  conjunctival  sac,  and 
to  erosions  and  fissures  at  the  corners  of  the  eyes. 

These  symptoms  are  associated  with  enlargement  of  the 
liver  and  .spleen,  affections  of  the  bov:eh,  pulmonary 
catarrh,  which  are  caused  by  aspiration  of  the  secretions 
from  diseased  buccal  and  nasal  cavities,  and  not  infre- 
quently cause  death  within  two  or  three  months. 

If  the  infant  lives  through  all  these  graver  troubles, 
other  phenomena  soon  make  their  appearance.  The  dis- 
eased epiphyses,  which  hitherto  had  escaped  notice, 
become  detached,  beginning  usually  at  the  humeral  joint. 
At  first  a  painful  swelling  appears  about  the  affected 
epiphysis  and  the  limb  hangs  down  as  if  it  were  ])aral- 
yzed.  Sometimes  it  is  possible  to  determine  the  condition 
by  the  abnormal  movability,  but  usually  the  picture  is 
simply  that  of  palsy. 

Even  after  all  the  symptoms  in  the  skin,  mucous  mem- 
branes, and  joints  have  disappeared,  the  children  are  still 
weak  and  anemic,  and  we  can  readily  understand  that 
they  suffer  more  severely  than  other  children  from  inter- 
current diseases,  such  as  bronchitis,  pneumonia,  intestinal 
catarrh,  etc. 

This  early  period  of  hereditary  syphilis  is  sometimes 
followed  by  late  forms,  like  the  tertiary  forms  of  ac- 
quired syphilis,  for  which  the  term  S3^hilis  hereditaria 
tarda  is  used. 

It  is  asserted  by  some  observers  that  this  late  form  of 
syphilis  may  occur  between  the  ages  of  sixteen  and 
twenty  or  over,  without  having  been  preceded  by  any 
other  form  of  the  disease.  But  it  is  to  be  remembered 
that  hereditary  syphilis  does  not  necessarily  produce  very 
marked  changes  in  the  child,  and  we  cannot  therefore 
agree  with  this  view.  Good  health  is  a  relative  term  and 
very  elastic  in  its  application.  A  slight  nose-trouble  and 
tardy  develo])ment  are  phenomena  which  may  easily 
escape  detection.  In  treating  advanced  forms  of  syphilis 
I  have  found  the  marks  of  severe  processes  in  the  skin, 
glands,  and  joints  which  had  not  been  attributed  to  syph- 


70  SYPHILIS. 

ilis.  There  is  still  a  general  impression  that  syphilis 
always  gives  rise  to  definite  symptoms,  especially  such 
as  can  only  be  cured  by  specific  treatment.  These  and 
many  other  reasons  account  for  the  different  and  erroneous 
views  which  are  held  about  the  late  form  of  hereditary 
syphilis. 

It  is  important  to  distinguish  between  infantile  ac- 
quired syphilis  and  the  hereditary  form.  I  have  often 
had  occasion  to  treat  patients  between  16  and  18  years 
of  age  for  the  later  forms  of  syphilis.  In  such  cases  the 
most  careful  inquiries  must  be  made  whether  the  parents 
ever  suffered  from  diseases  which  might  have  had  a  s})e- 
cific  origin,  what  the  history  of  the  confinements  in  the 
family  has  been,  whether  any  children  were  stillborn,  and 
whether  there  are  any  brothers  or  sisters  affected  with 
syphilis.  If  any  such  signs  of  hereditary  syphilis  were 
found,  the  patients  never  failed  to  show  disturbances  of 
development  or  other  signs  of  hereditary  disease.  If  no 
such  indications  were  found,  the  case  usually  turned  out 
to  be  a  tertiary  form,  the  infection  having  been  acquired 
early,  without  the  knowledge  of  the  patient  or  of  his 
family. 

The  late  forms  of  hereditary  syphilis  begin  to  show 
themselves  about  the  fifth  year,  sometimes  with  the  ap- 
pearance of  puberty  about  the  twelfth  year ;  we  have 
observed  them  to  last,  with  interruptions,  as  late  as  the 
twentieth  year. 

It  is  not  our  purpose  in  this  place  to  discuss  in  detail 
all  the  protean  forms  to  which  hereditary  syphilis  gives 
rise  sooner  or  later  in  the  organism ;  wo  shall  content 
ourselves  with  mentioning  the  most  striking  symptoms 
which  help  the  physician  to  determine  whether  a  given 
morbid  product  is  to  be  attributed  to  syphilis  or  not. 

To  Hutchinson  is  due  the  credit  of  collecting  a  group 
of  symptoms  which  enable  us  to  distinguish  tertiary 
hereditary  forms  from  acquired  syphilis  with  great  accu- 
racy. They  are :  A  deformity  of  the  permanent  upper 
incisors,  consisting  in  a  crescentic  notch  on  the  free  edge 


HEREDITARY  SYPHILIS.  71 

of  the  teeth.  A  dinnie.s.s  of  the  cornea,  or  an  existing 
interstitial  keratitis  (Plates  60a,  601) ;  black  plate),  and 
rapicUi/  increasing  deafness.  If  we  add  a  prominence  of 
the  frontal  protuberances,  flat  or  even  depressed  nose,  and 
fine  scars  at  the  angles  of  the  mouth,  the  upper  lip,  and 
the  mucous  membrane  of  the  lips,  radiating  from  the 
nares,  the  picture  is  complete.  Fournier  is  quite  right 
when  he  points  out  the  tardy  development  of  such  indi- 
viduals. They  look  like  children  even  at  the  age  of  16 
or  18;  the  genitals,  the  pubic  hairs,  the  breasts  in  the 
female  subjects,  are  imperfectly  developed. 

As  to  the  symptoms  of  tardy  syphilis,  they  include 
the  lesions  in  the  bones  and  joints  which  we  find  in  the 
acquired  form,  and  skin-lesions  in  the  form  of  gum- 
matous, serpiginous  ulcers.  The  skin  of  the  nose  seems 
to  be  a  favorite  seat.  This  is  perhaps  due  to  the  chronic 
catarrh  which  is  so  often  present ;  ulcers  gradually  form, 
the  process  spreads  to  the  cartilages  and  to  the  bones,  and 
at  last  the  external  skin  is  also  destroyed. 

Certain  groups  of  lymph-glands,  notably  the  cervical 
glands,  undergo  a  peculiar  form  of  hyperplasia  resulting 
in  large  tumors,  which  show  no  tendency  to  soften  or 
break  down.  The  condition  usually  lasts  a  long  time 
and  resists  treatment  much  more  stubbornly  than  do  the 
other  symptoms.  Such  glandular  tumors  resendile  sar- 
coma.^ 

The  internal  organs,  liver,  spleen,  and  kidneys,  are 
usually  enlarged,  and  often  irregularly  contracted  by 
gummata  and  cord-like  neoplasms.  The  most  frequent 
alteration  in  these  organs  is  amyloid  degeneration,  espe- 
cially if  the  patient  is  debilitated. 

The  nervous  system  does  not  escape  the  ravages  of  the 
morbid  process.  The  patients  frequently  suffer  with 
epilei)tiform  attacks ;  they  possess  a  low  order  of  intel- 
ligence and  are  sometimes  even  half-witted.  The  same 
diseases  of  the  meninges,  the  arteries,  and  of  the  brain- 
substance  occur  as  are  found  in  acquired  syphilis,  and  the 

'  As  in  one  of  my  cases  in  the  Kudolfsspital ;  see  Yearly  Report,  1892. 


72  SYPHILIS. 

diagnosis  must  be  based  on  the  evidences  of  the  presence 
of  syphilitic  processes  in  other  parts  of  the  body  and  on 
the  loss  of  the  cerebral  functions. 

It  is  difficult  even  to  outline  the  proper  treatment 
for  hereditary  syphilis.  In  every  case  the  patient 
requires  the  most  careful  management,  if  there  is  to  be 
even  a  chance  of  success.  Drugs  should  be  administered 
from  time  to  time,  particularly  iodids  and  tonics ;  in  the 
early  forms  modified  inunction  cures  and  sublimated 
baths  may  be  employed.  The  greatest  benefit  is  derived 
from  careful  dieting,  good,  pure  air,  and  baths  containing 
iodids — more  than  from  a  general  treatment. 

THE  TREATMENT  OF  SYPHILIS. 

We  shall  divide  the  treatment  of  syphilis  into  three 
subdivisions:  1.  Initial  forms  and  their  immediate  con- 
sequences ;  2.  Local  treatment  of  the  secondary  and  ter- 
tiary lesions;  3.  General  treatment  of  syphilis. 

I.  Initial  Forms  and  Their  Immediate  Consequences. 

It  is  the  duty  of  the  physician  to  treat  every  sus- 
picious lesion  as  if  syphilitic  infection  had  actually 
occurred.  The  ruling  principle  must  be  to  destroy  the 
syphilitic  germ  at  the  point  of  infection  as  soon  as  possible. 
As  we  have  seen  by  the  pathology,  the  first  diagnosis  can 
only  be  a  provisional  one,  even  if  the  case  is  seen  in  the 
first  few  days,  but  the  physician  is  nevertheless  justified 
in  adopting  energetic  measures  at  once.  It  is  impossible 
to  say  how  long  the  virus  remains  at  the  point  of  entry ; 
certainly  a  very  short  time,  for  I  have  never  had  any 
good  results  from  excision  of  a  simple  initial  sore  within 
thirty-six  or  even  twenty-four  hours.  Although  these 
excisions  were  made  before  any  evidences  of  reaction  to 
the  poison  had  made  their  appearance,  the  virus  was  not 
removed,  showing  that  it  had  already  been  communicated 
to  the  vessels  and  other  parts  of  the  body  outside  of  the 


THE  TREATMENT  OF  SYPHILIS.  73 

initial  sore.  Nevertheless,  excision  is  advisable  in  certain 
seats  of  syphilitic  infection  which  are  favorably  situated 
for  operation,  as  fissures  in  the  preputial  margin,  in  the 
edges  of  the  labia,  etc.  The  excision,  to  be  justifiable, 
must  be  made  within  the  first  few  hours  after  infection ;  I 
have  never  known  it  to  be  successful  in  cases  where  a 
beginning  infiltration  or  even  a  complete  sclerosis  could 
be  demonstrated,  although  the  treatment  of  the  initial 
lesion  was  somewhat  simplified  by  the  operation.  What 
has  been  said  about  excision  is  equally  true  of  the  use  of 
the  thermocautery ;  the  burn  must,  however,  be  treated 
longer  tiian  the  wound  from  an  excision,  which  may  be 
allowed  to  heal  by  first  intention.  Cauterization  is  indi- 
cated only  when  the  sclerosis  has  become  phagedenic  and 
is  rapidly  degenerating. 

In  the  initial  forms  we  confine  ourselves  as  a  rule  to 
the  antiseptic  treatment,  using  the  customary  drugs,  corro- 
sive sublimate,  carbolic  acid,  salicylic  acid,  etc.  For 
many  reasons,  learnt  in  the  prophylactic  treatment  of 
syphilis,  it  is  not  advisable  to  begin  a  general  treatment 
at  once,  except  in  cases  where  the  sclerosis  is  seated  on 
the  face — at  the  lips,  for  instance — and  tends  to  degen- 
erate rapidly,  with  the  formation  of  large  glandular 
tumors.  In  such  cases  the  practice  has  always  been  to 
endeavor  to  stay  the  destructive  process  by  immediate 
resort  to  general  treatment. 

In  the  male  genitals  the  sclerosis  is  usually  seated 
on  the  prepuce  itself  or  in  the  neck  of  the  penis,  and  is 
often  associated  with  phimosis.  If  the  foreskin  Avas  too 
long  originally  (prseputium  perlongum),  and  is  converted 
into  a  hard  mass  by  the  infiltration  spreading  beyond  the 
initial  sclerosis,  it  must  be  removed  with  the  knife  in 
order  to  shorten  the  treatment  and  put  an  end  to  the 
patient's  distress.  It  is  not  necessary,  or  even  advisable, 
to  remove  the  entire  prepuce ;  it  is  enough  to  open  the 
preputial  sac  at  the  dorsum  and  excise  a  portion  of  it. 

If  the  sclerosis  becomes  gangrenous  and  destroys  the 
inner  layer  of  the  foreskin  or  the  neck  of  the  penis,  im- 


74  SYPHTLTS. 

mediate  operation  becomes  necessary.  After  the  opera- 
tion sucii  phimoses  heal  readily  and  give  no  further 
trouble ;  even  the  remains  of  the  edges  of  the  sclerosis 
heal  and  leave  a  scar. 

If  there  is  a  paraphimosis  from  forced  retraction  of  the 
infiltrated  prepuce,  surgical  interference  becomes  neces- 
sary to  prevent  furtiier  destruction  of  the  prepuce  and  of 
the  skin  of  the  penis  by  the  pressure  of  the  constricting 
preputial  ring. 

The  dorsal  lymphatics,  owing  to  the  infiltration  in  sim- 
ple, non-ulcerative  scleroses,  are  converted  into  hard, 
sometimes  nodular  welts ;  these  may  be  covered  with 
strips  of  gray  plaster ;  they  soon  disappear  when  the 
general  treatment  is  begun  later  on. 

The  glandular  swellings  of  syphilis  rarely  go  on  to 
suppuration  unless  they  are  complicated  with  venereal 
ulcers,  or  the  patients  are  scrofulous  or  otherwise  debili- 
tated. In  such  cases  the  adenitis  is  to  be  treated  sur- 
gically in  the  manner  indicated  in  the  section  on  vene- 
real ulcers. 

In  treating  scleroses  in  the  female  genitals  the  only 
difficulties  are  encountered  in  applying  the  remedy  and 
getting  the  bandage  to  stay.  Powders  and  strips  of  gray 
plaster  are  employed  with  advantage ;  a  T-shaped  band- 
age will  keep  the  dressing  on  the  external  genitals  in 
place. 

Scleroses  at  the  orifice  of  the  urethra  and  about  the  amis 
may  be  treated  at  first  with  bougies  and  suppositories  of 
iodoform  (iodoformi  puri,  0.1  (gr.  xv) ;  olei  theobromai, 
q.  s.  u,  f.  suppositor.  urethrale),  and  later  with  strips  of 
gray  plaster.  Sometimes  a  dressing  of  antiseptic  gauze, 
saturated  with  a  5  per  cent,  solution  of  white  precipitate 
or  a  1  to  3  per  cent,  solution  of  red  precipitate  may  be 
employed  with  advantage.  The  dressing  must  be  changed 
from  one  to  three  times  a  day,  according  to  the  amount  of 
secretion,  and  the  ulcer  cleansed  each  time  with  carbolic 
acid  or  corrosive  sublimate. 


THE  TREATMENT  OF  SYPHILIS.  75 

2.   Local  Treatment  of  the  Secondary  and   Tertiary 
Lesions. 

In  S3^hilitic  affections  of  the  mouth,  nose,  and 
throat  the  patient  must  use  a  mouth-wash  and  gargle 
several  times  a  day,  especially  after  meals  and  before 
retiring  at  night. 

The  following  prescriptions  are  recommended : 

I^.  Pot.  chlor.,  10.0  (sijss) ; 

Aq.  dest.,  500.0  (Oj). 

S.  :  Gargarisma. 

i;^.  Pot.  chlor.,  10.0  (.5ijss)  ; 

Alum,  crud.,  1.0(gr.  xv); 

Aq.  dest.,  400.0  (fsxiij)  ; 

Aq.  menth.  pip.,  100.0  (f,§iij). 
S. :  Gargarisma. 

'Sf.  Acid,  borac,  10.0  (sijss) ; 

Solve  in  aq.  dest.,  500.0  (Oj). 

S. :  For  external  use. 

]^.  Acid,  salicyl.,  3.0  (gr.  xlv)  ; 

Spirit,  vin.  rectif.,  30.0  (f  §j) ; 

Aq.  dest.,  300.0  (f  .?x)  ; 

Tinct.  kramerise,  gtt.  xxx  ; 

Pot.  hypermang.,  5.0  (.^jss)  ; 

Aq.  dest.,  100.0  (fsiij). 
S. :  One  tablespoonful  to  a  glass  of  water  for  mouth- 
Mash  and  gargle. 

I^.  Tinct.  cascarillse, 
Tinct.  cinchonse, 
Tinct.  kramerise, 

Spirit,  menth.  pip.,   aa.  25.0  (3vj). 
S. :  Twenty  drops  to  a  glass  of  water  for  mouth-wash. 

Ulcerative,  papular  sores  on  the  mucous  mem- 
brane of  the  lips  and  cheeks  and  on  the  isthmus 


76  SYPHILIS. 

of  the  fauces  must  be  touched  with  nitrate  of  silver 
every  day  by  the  physician  himself  (solid  nitrate  or  a 
5  per  cent,  solution).  If  the  patient  is  a  responsible 
person,  he  may  be  trusted  with  a  sublimate  mouth-wash, 
either  in  the  form  of  tablets  prepared  with  XaCl,  1  gram 
(gr.  xv)  each,  to  be  dissolved  in  water,  and  used  in  the 
proportion  of  one  tablespoon ful  of  the  solution  to  ten 
tablespoonfuls  of  water  as  a  gargle ;  or 

I^.  Hydr.  bichlor.  corros.,       1.0  (gr.  xv)  ; 
Alcohol,  absol.,  50.0  (f.5Jss). 

S. :  Poison. — One  tablespoonful  to  a  glass  of  water 
for  mouth- wash. 

These  sublimate  gargles  are  to  be  used  two  or  three 
times  a  day,  an  entire  glassful  being  used  each  time. 

Ulcers  and  fissures  on  the  tongue  must  also  be 
touched  with  nitrate  of  silver.  Hard  infiltrates  on  the 
surface  of  the  tongue  should  be  painted  with  a  more  con- 
centrated alcoholic  solution  of  sublimate,  or  with  tincture 
of  iodin,  once  or  twice  a  day. 

Destructive  gummata  and  ulcers  on  the  mucous 
membranes  must  be  energetically  treated  with  solid  nitrate 
of  silver  and  thoroughly  cleansed  with  one  of  the  above- 
mentioned  mouth- washes  or  with  an  irrigator.  In  using  an 
irrigator  for  the  nasal  cavity,  care  must  be  had  not  to  exert 
too  much  pressure,  lest  the  liquid  be  forced  into  the  cranial 
cavity  or  into  the  Eustachian  tube  and  cause  pain.  If 
there  are  any  necrotic  bone-fragments  at  the  bottom  of 
the  ulcers  or  between  the  proliferations  of  granulation- 
tissue,  they  must  be  removed  as  soon  after  they  liave 
separated  as  possible.  If  the  operation  is  attended  with 
hemorrhage,  which  is  often  the  case,  absorbent  cotton  or 
adhesive  iodoform  gauze  may  be  used  to  control  it. 

The  local  treatment  of  laryngeal  syphilis  requires 
some  proficiency  in  the  use  of  the  laryngeal  mirror  and 
other  instruments,  and  should  only  be  attempted  by  a 
specialist.  Inhalation  of  the  vapors  of  iodid  solutions 
(2  per  cent,  potassium  iodid),  as  an  adjunct  to  the  general 


THE  TREATMENT  OF  SYPHFLrS.  7? 

treatment,  is  allowable  in  very  light  eases  ;  it  is,  however, 
usually  inadequate  for  the  removal  of  the  larger  forms 
of  papules,  or  of  extensive  infiltrations,  or  even  of  deep 
gummy  ulcers. 

For  papular  syphilides  on  the  genitalia  and 
anus,  the  most  frequent  form  of  syphilis  in  the  female, 
and  very  apt  to  recur  in  both  sexes,  we  use  Labarraque's 
dressing  : 

^.  Chlorin.  liquid.,  20.0  (ftv)  ; 

Aq.  dest.,  80.0  (f.^ijss). 

S. :  Apply  with  a  brush. 
And 

I^.  Calomel, 
Amyl,     da. 
S. :  Dusting-powder. 

The  papules  are  first  moistened  with  the  chlorin- 
water  and  then  dusted  with  calomel.  Sublimate  in  the 
nascent  state  is  thus  formed,  which  acts  as  an  intense 
caustic  without  giving  nuich  pain. 

In  the  severe  hyperplastic  forms  affecting  the  labia 
majora,  the  perineum,  and  the  nates,  the  infiltration  may 
be  made  to  subside  rapidly  by  painting  daily  with  a 
stronger  alcoholic  or  ethereal  solution  of  sublimate  (1  :  20) 
and  covering  the  moistened  parts  with  strips  of  cotton. 
The  use  of  caustics,  such  as  sublimate  collodium  (1  :  20), 
Plenck's  solution  \  and  others,  has  been  given  up  as  too 
dangerous  as  well  as  painful.  Even  the  solution  we  have 
indicated  must  be  applied  with  great  care,  so  as  not  to 
touch  any  but  the  hyperplastic  tissues ;  if  the  burning  is 
severe,  it  should  be  followed  by  the  application  of  alum- 
inum acetate  or  Burow's  solution  in  the  form  of  com- 


»B. 

Hydr.  chlor.  corros., 

Aliiminis, 

aa-  .^j  ; 

Plumb,  acetat., 

Camphor., 

da.  Sj ; 

Alcohol., 

Acid,  acet., 

act.  gxij 

78  SYPHILIS. 

presses.    Inunctions  with  stronger  white  precipitate  some- 
times have  a  good  etTect. 

^.  Hydrarg.  ammoniat.,         5.0  (ojss)  ; 
Unguent,  emollient.,         40.0  (.^x) ; 

either  alone  or  reinforced  by  0.1  (gr.  jss)  sublimate. 

For  flat  papules  which  do  not  secrete  much  a  good 
adhesive  gray  plaster  answers  every  purpose. 

Fissures  about  the  anus,  which  are  usually  found 
close  to  proUfei-ated  anal  folds,  often  defy  all  remedies  and 
are  best  treated  surgically.  The  proliferations  are  re- 
moved with  Paquelin's  thermocautery,  the  patient  being 
anesthetized,  and  the  wound  is  afterward  dressed  with 
iodoform  vaselin  or  with  white-precipitate  ointment. 
Tying  the  infiltrated  folds  with  elastic  ligatures  is  not 
to  be  recommended,  although  I  formerly  employed  that 
method  in  a  good  many  cases  without  injury  to  the 
patients. 

Palmar  and  plantar  psoriasis,  fissures  and 
degenerating  papules  between  the  toes  and  on 
the  fingers.  In  all  these  forms  the  hands  and  feet  should 
be  softened  by  soaking  in  warm  water  (with  soap)  and 
then  dressed  with  good,  soft  gray  plaster.  Deep  fissures 
or  ulcers  with  signs  of  inflammation  are  to  be  treated 
with  baths  and  compresses  dipped  in  Burow's  solution. 
Sometimes  it  is  advisable  to  apply  sublimate  solutions 
(1  :  1000)  in  addition  to  the  bathing.  A  very  good  plan 
is  to  rub  the  affected  parts  with  the  above-mentioned 
white-precipitate  ointment  (4:40,  with  0.1  to  0.2  (gr.  jss 
to  iij)  sublimate)  after  bathing  them  at  night,  and  then 
to  put  on  a  pair  of  Swedish  leather  gloves. 

Syphilitic  onychia  and  paronychia  are  treated 
with  Avarm-water  baths,  compresses,  and  washing  with 
sublimate,  the  diseased  end-phalanges  being  well  tied  up 
in  caps  of  gray  plaster.  If  the  edges  of  the  nails  are 
turned  in,  a  local  anesthetic  is  administered,  the  nail  is 
split,  and  the  edges  are  cut  away.     A  protecting  bandage 


TlIK  TREATMENT  OF  SYPHILIS.  79 

or  finger-cot  should  be  worn  constantly  until  the  nail 
grows  again.  » 

In  diseases  of  the  scalp,  which  we  have  described,  some 
form  of  local  treatment  is  always  necessary.  First  of  all, 
the  hair  is  to  be  cut  short.  The  patient  must  wash  his 
head  every  day  with  soap  and  water  and  rub  it  with 
white-precipitate  ointment  (1  :  10).  If  pustular  ulcers  or 
deep,  destructive  gurnmata  are  present,  the  scalp  must  be 
dressed  with  iodoform  vaselin,  mercurial  ointments,  or 
with  gray  plaster,  and  the  dressing  held  in  place  by  a 
properly  applied  head-bandage.  Carious  bone-lamelhe 
either  separate  of  their  own  accord  or,  if  necessary,  are 
removed  with  forceps.  The  local  treatment  must  never 
be  omitted,  as  it  may  be  the  means  of  avoiding  an 
extensive  necrosis  of  the  bone  even  when  large  areas  are 
exposed.  I  have  seen  holes  in  the  skull  as  large  as  a  dol- 
lar heal  over  and  form  a  scar.  If  the  loss  of  bone-sub- 
stance is  considerable,  insert  plates  of  celluloid  after  the 
scar  has  formed,  in  order  to  protect  the  brain. 

The  treatment  for  the  various  cutaneous  processes, 
the  muscle-,  bone-,  and  joint-lesions  of  the  later 
stages  of  syphilis,  cannot  Avell  be  reduced  to  a  schedule. 
If  the  numerous  external  remedies  are  insufficient  to  con- 
trol the  process,  and  surgical  interference  is  indicated,  it 
should  not  be  delayed  too  long.  We  are  getting  over  our 
reluctance  to  operate  on  syphilitic  patients. 

3-  General  Treatment  of  Syphilis. 

To  begin  with,  the  so-called  expectant  treatment,  by  which 
is  meant  the  regulation  of  the  diet  and  other  hygienic  con- 
ditions, without  the  use  of  the  specifics  mercury  and  iodin 
for  the  local  lesions,  is  in  our  opinion  entirely  inadequate. 

As  soon  as  syphilis  produces  lasting  functional  disturb- 
ances in  the  circulatory  organs,  neuralgias  or  pathological 
changes  in  the  skin  or  mucous  membranes  remote  from  the 
point  of  infection,  the  physician  must  begin  a  specific  mercu- 
rial treatment  and  persist  in  it  until  the  morbid  symptoms 


80  SYPHILIS. 

have  disappeared  completely.  In  fact,  experienced  prac- 
titioners make  it  a  rule  to  continue  the  treatment  for  a 
period  equal  to  at  least  a  third  or  even  a  half  of  the  dura- 
tion of  the  symptoms,  after  the  latter  have  disjippeared. 

Any  subsequent  relapse,  if  accompanied  by  marked 
alterations  in  various  parts  of  the  body,  must  again  be 
subjected  to  both  general  and  local  treatment.  Thus  we 
follow  the  pathological  process  and  keep  the  patient 
under  observation,  treating  him  with  mercury,  or  later 
with  iodid,  only  when  he  actually  shows  unmistakable 
syphilitic  symptoms.  We  do  not  advocate  the  practice 
of  giving  drugs  at  definite  intei'vals,  whether  the  symp- 
toms are  present  or  not  (chronic  intermittent  treatment 
— Fournier),  because  we  have  noticed  that  such  a  course 
does  not  prevent  the  recurrence  of  the  symptoms  after  a 
certain  period ;  besides,  the  patient  becomes  accustomed 
to  the  drug  and  does  not  respond  so  readily  when  it  be- 
comes necessary  to  give  it  to  him  at  the  next  outbreak  of 
the  disease.  But  this  is  not  the  place  to  discuss  this  ques- 
tion in  detail ;  we  only  wished  to  define  our  position. 

For  headache,  insomnia,  and  other  distressing  symptoms 
which  sometimes  occur  during  the  eruptive  period,  we 
prescribe : 

^.  Pot.  brom., 

Sod.  brom.,  aa.  4.0  (3J)  ; 

Ammon.  brom.,  2.0  (3ss). — M. 

Ft.  pulv.  No.  X. 
S. :  1  or  2  powders  at  bedtime. 
Or 

^.  Pot.  brom.. 

Pot.  iod.,  ad.  0.5  (sjss). — M. 

Ft.  pulv.  No.  X. 
S. :  1  or  2  powders  at  bedtime. 

Before  the  appearance  of  the  exanthemata  and  in  the 
intervals  between  the  relapses  (if  there  are  any)  and  the 
consequent   specific   treatment,  we   have   various   duties 


THE  TREATMENT  OF  SYPHILIS.  81 

toward  the  patient  to  fulfil.  We  must  prepare  Mm  for 
the  various  forms  of  mercurial  treatment — the  mouth  and 
the  skin  must  be  looked  after,  the  initial  lesion  treated 
locally  ;  and  after  the  course  of  specific  treatment  is  over 
he  requires  a  supplementary  one,  such  as  medicinal  baths, 
tonics,  etc. 

The   Care   of   the    Mouth    before   and    during 
Mercurial   Treatment. 

We  cannot  emphasize  too  strongly  that  a  systematic, 
careful  treatment  and  supervision  of  the  mouth  is  an  abso- 
lute necessity  during  the  entire  course  of  mercurial  treat- 
ment, and  even  longer.  The  patient  must  clean  his  teeth 
thre«  or  four  times  a  day  Avith  brush  and  powder.  In  our 
hospital  practice  we  use  the  following : 

I^.  Pulv.  dentifr.  nigr.,  50.00  (gjss). 
Or 

I|i.  Calcar.  carbon,  pulv.,  50.00  (§jss)  ; 

Magnes.  carb.,  10.00  (sijss) ; 
Pulv.  rad.  ir.  flor.  (orris),      20.00  (sv) ; 
Olei  menth.  pip.,  (gtt.  Ix).— M. 

S. :  Tooth-powder. 

After  that  the  gums  are  ])ainted  with  an  astringent 
tincture,  and  then  rinsed  with  water. 

I^.  Tinct.  iodin., 

Tinct.  gall.,  aa.  10.00  (sijss). 

S. :  Apply  with  brush. 


Or 


Or 


I^.  Tinct.  kramerise, 

Tinct.  gall.,  aa.  20.00  (sv) ; 

Olei  menth.  pip.,  (gtt.  xl). 

S. :  Gum  tincture. 

^.  01.  cadin., 

Spir.  vin.,  da.  10.00  (sijss)  ; 

Tinct.  laud,  simp].,  5.00  (3Jss). 


82  SYPHILIS. 

As  a  gargle  we  prescribe  hypermanganate  of  potassium 
in  the  usual  pink  solution,  0.5  to  2  per  cent,  potassium 
chloric!,  in  solutions  of  1  to  2  per  cent,  with  the  addition 
of  alum,  or 


Or 


^t.  Aq.  calcis, 

Aq.  destill.,  ad. 

^i.  Acidi  salicyl.,  5.00  (3Jss) ; 

Spir.  frument., 

Aq.  destill.,  da.  100.00  (f  3iij) ; 

Ol.  menth.,  (gtt.  v).— M. 

S. :  One  teaspoon ful  to  a  glass  of  water. 

In  mercurial  stomatitis,  in  addition  to  the  above- 
mentioned  local  measures,  we  paint  the  gums  with  nitrate 
of  silver  (1  :  30  to  1  :  15),  rinsing  the  mouth  with  a  saline 
solution,  or  with  a  15  to  25  per  cent,  watery  solution  of 
chromic  acid.  Erosions  and  ulcers  are  touched  with  the 
solid  stick  of  silver  nitrate,  or  the  recently  suggested 
combination  of  silver  nitrate  with  a  25  per  cent,  solution 
of  chromic  acid  may  be  employed.  By  this  method  the 
newly  formed  argentic  chromate  leaves  a  red  scab  on  the 
surface  of  the  ulcer. 

Mercurial  Treatment  of  Syphilis. 

Tiie  sovereign  method  of  applying  a  mercurial  cure  is 
inunction  with  gray  mercurial  ointment;  it  is 
applicable  not  only  to  all  forms  of  syphilis,  but  to  all 
ages  as  well. 

The  infant  can  be  rubbed  by  the  mother  or  nurse  after  the 
morning  bath  with  dilute  mercurial  ointment  (1.0  (gr.  xv) 
unguent,  ciner.  with  1.0  (gr.  xv)  ung.  simpl.)  on  the  sides  of 
the  thorax  and  on  the  abdomen.  An  adult  weighing  about 
60  kg.  should  use  from  4  to  5  g.  (,^j  to  ,gss)  daily.  The 
inunction  ought  to  be  performed  by  an  expert  masseur, 
but   if  that    is   impossible,  as   in   hospital   practice,  the 


THE  TREATMENT  OF  SYPHILIS.  "     83 

patient  must  be  taught  to  do  it  himself.  A  small  amount 
of  the  ointment  is  taken  at  a  time  and  rubbed  in  alter- 
nately on  both  sides  of  the  body  till  the  skin  is  quite  dry. 
The  places  selected  for  the  inunction  are  usually  the 
calves  of  the  leg,  the  inner  surfaces  of  the  thighs,  the  epi- 
gastric region,  the  lateral  regions  of  the  thorax,  the  inner 
surface  of  the  upper  arm  and  forearm,  and  the  back. 
After  all  these  parts  have  been  well  rubbed,  the  patient 
should  take  a  warm  bath  for  the  sake  of  cleanliness. 

The  inunctions  are  to  be  kept  up  until  all  the  symp- 
toms have  disappeared,  and  after  that  for  an  additional 
period  equal  to  one-third  or  one-half  of  the  time  occupied 
by  the  original  treatment.  If  the  patient  is  unwell  from 
any  accidental  cause,  or  if  he  suddenly  develops  pro- 
nounced mercurial  salivation  and  stomatitis,  the  treat- 
ment must  be  discontinued  for  a  few  days  until  the 
troublesome  symptoms  have  subsided,  and  then  resumed. 
There  is  no  objection  to  repeating  the  treatment  for  every 
one  of  the  many  relapses  which  usually  mark  the  course 
of  a  syphilitic  disease. 

In  addition  to  the  inunctions,  other  measures,  such  as 
the  baths  we  have  referred  to,  and  internal  remedies, 
tonics,  etc.,  may  be  employed. 

The  patient  must  be  well  fed  and  housed  while  he  is 
undergoing  the  treatment.  If  his  work  exposes  him  to 
hardship  and  fatigue,  especially  to  the  inclemencies  of  the 
weather,  the  treatment  should  not  be  used.  We  have 
never  seen  any  good  result  from  it  under  such  circum- 
stances ;  the  patient  becomes  anemic  and  the  treatment 
seems  to  do  him  more  harm  than  good,  so  that  he  only 
loses  faith  in  it. 

The  physician  must  give  his  attention  to  the  care  of 
the  mouth,  as  in  all  forms  of  mercurial  treatment,  and 
also  to  the  digestive  organs  and  to  the  excretions.  AVe 
have  on  several  occasions  found  albumin  in  the  urine, 
and  have  been  obliged  to  reduce  the  dose  or  to  interrupt 
the  treatment ;  in  a  few  cases  we  have  even  been  com- 
pelled to  give  it  up  altogether. 


84  SYPHILIS. 

After  the  specific  treatment  is  completed,  the  patient's 
mode  of  life  must  be  properly  regulated  ;  a  mild  water- 
cure,  invigorating  baths  (salt-water  baths),  or,  if  possible, 
removal  to  a  milder  climate,  should  be  recommended  to 
supplement  the  specific  cure.  The  mouth  needs  careful 
attention  for  weeks  after  the  specific  treatment  is  com- 
pleted. 

For  the  inunctions  we  prescribe  in  the  case  of  adults : 

]^.  Ung.,  ciner.,  4.0-5.0  (sj  to  3jss) ; 

Dent.  tal.  dos.  ad  chart,  cerat.  No.  v. 
(Dispense  five  such  doses  in  waxed  papers.) 
S. :  To  be  rubbed  in  (as  indicated  above). 

According  to  the  Austrian  Pharmacopea,  7th  edition,  the 
ointment  is  prepared  as  follows  : 

^.  Hydrarg., 

Lanolin.,  eta.  200.0    (Ivj) ; 

mix  until  completely  fused,  and  gradually  add — 

Ung.  simp].,  200.0    (5vj). 

For  extensive  cutaneous  syphilids,  multiple 
ulcerative  processes  on  the  surface  of  the  body,* 
cutaneous  exanthemata  of  the  skin,  and  for 
weeping  papules  in  small  children,  sublimate  baths 
should  be  employed.  10-15  g.  (sijss-pjv)  in  tablets. 
For  adults  10-15  g.  (sijss-^jv)  of  sublimate  solution  are 
added  to  a  bath  of  from  three  to  five  buckets  of  water  at 
26°  to  28°  R.  (32.5°  to  35°  C.) ;  the  patient  remains  in 
the  tub  from  ten  to  fifteen  minutes,  during  which  time  he 
is  gently  rubbed.  After  the  bath  he  must  stay  in  bed. 
Young  children  are  simply  sponged  with  the  solution  once 
or  twice  a  day  ;  the  diseased  portions  of  the  skin  are  first 
carefully  washed  and  then  dusted  Avith  a  suitable  powder 
(pure  starch  or  starch  mixed  with  calomel). 


THE  TREATMENT  OF  SYPHILIS.  85 

Hypodermatic  Methods. —  {a)  Soluble  Mercurial 
Preparations : 

I^.  Hydrarg.  bichlor.  corros.,       0.10  (gr.  jss); 
Sodii  clilorati  depurati,  1.00  (gr.  xv) ; 

Aq.  destill.,  10.00  (t'sijss). 

Inject  one  syringeful  of  this  solution  daily,  either  sub- 
cutaneously  in  the  back,  or  between  the  muscles  (intra- 
muscular injection)  in  the  nates. 

The  following  solution  has  been  employed  with  great 
success,  especially  in  the  treatment  of  "  walking  cases  "  : 

I|«.  Hydrarg.  bichlor.  corros.,      0.5  (gr.  viij) ; 
Sodii  chlorati,  2.00  (sss)  ; 

Aq.  destill.,  10.00  (fgijss). 

Inject  one  syringeful  of  this  solution  at  intervals  of 
five  days  or  a  week.  If  the  precaution  is  taken  to  disin- 
fect thoroughly  both  the  syringe  and  the  place  where  the 
point  is  to  be  inserted,  and  the  injection  is  followed  by 
gentle  massage  of  the  part,  there  is  practically  no  danger 
that  the  wound  will  be  painful  or  that  an  abscess  will 
form. 

(6)  Insoluble  Mercurial  Preparations. — The  use  of  these 
preparations  is  to  be  avoided,  as  a  rule,  for  they  all  have 
the  disadvantage  that  the  amount  of  mercury  absorbed 
necessarily  remains  an  unknown  quantity,  as  absorption 
varies  greatly  according  to  circumstances  which  cannot  be 
controlled.  Grave  accidents  sometimes  occur  in  conse- 
quence of  the  sudden  absorption  of  large  quantities  of 
the  material  supplied. 

However,  we  give  some  of  the  more  common  formulae  •. 

^.  Hydrarg.  salicyl.,  1.00  (gr.  xv); 

Olei  oliv.  optim.,  10.00  (sijss). — M. 
S. :  To  be  injected. 

Shake  before  using. 


86  SYPHILIS. 

1^.  Hydrarg.  oxid.  flav.,  1.00  (gr.  xv) ; 

Olei  oliv.  optim.,  10.00  (sijss). — M. 
S. :  To  be  injected. 

Shake  before  using. 

I^.  Calomelan.,  1.00(gr.  xv); 

Olei  oliv.  optim.,  10.00  (sijss).— M. 
S.  :  To  be  injected. 

Shake  before  using. 

Internal  Use  of  Mercury. — This,  as  is  well  known, 
is  the  prevalent  mode  of  treating  syphilis  in  many  coun- 
tries. In  this  country  (Austria)  it  is  used  only  for  mild 
cases  of  relapse,  and  we  do  not  recommend  it  under  any 
other  circumstances. 

I^.  Hydrarg.  tannic,  oxidul.  (oxidu- 

lated  mercuric  tannate),         1.50  (gr.  xxiv) ; 
Extr.  laudan.,  0.10  (gr.  jss).— M. 

Div.  in  dos.  No.  xv.  D.  ad  capsul.  nebulos. 
S. :  One  pill  after  meals  t.  d. 

'Bf.  Hydrarg.  bichlor.  corros.,  0.30  (gr.  v) ; 

Extr.  et  pulv.  rad.  acori,      da. 

q.  s.  f.  pil.  pond.,  0.20  (gr.  iij). 

No.  XXX  ;  consperge  pulv.  liquirit. 
S. :  One  pill  every  evening.     Increase  the  dose  by  one 
pill  every  day  up  to  3  or  4  pills  a  day. 

"Sf.  Hydrarg.  iodid.  flav.,  1.50  (gr.  xxiv)  ; 

Extr.  laudan.,  0.50  (gr.  viij) ; 

Pulv.  et  extr.  gent.,  q.  s.  ft.  pilul. 

pond.,  0.20  (gr.  iij). 

No.  1. 
S. :  1  or  2  pills  twice  a  day. 

Use  of  the  Iodids  in  Syphilis. 

While  the  value  of  the  various  mercurial  preparations 
in  the  treatment  of  syphilis  is  well  established,  and  they 


THE  TREATMENT  OF  SYPHILIS.  87 

are  foiintl  to  be  well  nigh  indispensable  in  four-fifths  of 
the  cases,  the  iodids  form  a  most  useful  addition  to  the  list 
of  specific  remedies.  The  iodids  are  indicated  in  general 
glandular  enlargements,  in  the  scrofulous  diathesis,  in 
accidental  nervous  complications  such  as  headache  and 
insomnia,  and  in  cases  where  a  long-continued  course  of 
mercury  has  proved  useless.  We  must  not  be  deterred  by 
the  incidental  effects  of  iodid,  such  as  catarrh  of  the  nose, 
of  the  conjunctivae,  and  of  the  respiratory  tract,  frontal 
headache,  and  often  gastric  disturbances.  After  the  treat- 
ment has  been  omitted  for  a  few  days  and  the  symptoms 
have  subsided,  it  may  be  resumed  with  smaller  doses,  until 
the  organism  gradually  becomes  accustomed  to  the  drug. 
In  the  case  of  some  patients,  Avho  at  first  complained  of 
innumerable  symptoms  and  protested  vigorously  against 
the  drug,  I  have  been  able  eventually  to  give  the  maximum 
dose,  5  to  10  to  15  g.  (giss  to  Siv),  either  by  gradually  in- 
creasing the  dose  or  by  varying  the  form. 

I^.  Pot.  iodid.,  1.5  (gr.  xxiv) ; 

Aq.  destill.,  100.0  (f  giij). 

S. :  Divide  into  2  or  3  portions  and  drink  during  the 
day,  diluting  in  fresh  water. 

A  better  way  is  to  give  the  patient  some  potassium  iodid 
in  a  well-corked  vial  and  let  him  prepare  the  solution 
himself.  He  can  carry  it  about  with  him  more  easily, 
and  the  iodid,  which  is  very  sensitive  to  moisture,  is  pro- 
tected from  the  air  and  from  dampness.  If  he  is  to  in- 
crease the  dose,  he  has  his  remedy  always  ready  at  hand. 
Some  patients  prefer  to  add  a  little  fruit  juice  to  the  solu- 
tion in  order  to  disguise  the  taste,  others  prepare  a  con- 
centrated watery  solution  and  take  it  with  milk. 

Sodium  iodid  contains  less  iodin  than  the  potassium 
salt ;  it  mav  be  given  in  the  same  form  ;  some  patients 
take  it  more  easily  than  the  other   preparation. 

Iodoform  is  not  so  suitable  for  internal  use  on  account 
of  its  disagreeable  taste ;  it  can  only  be  taken  in  the  form 
of  pills. 


88  SYPHILIS. 

'Bf.  lodof.  pur.,  10.0(3ijss); 

Extr.  et  pulv.  acor. 
ad.  q.  s.  f.  pil.  pond.  0.2  (sss). 

No.  c,  obteg.  lamin.  argent,  (wrap  in  silver 
foil). 
S. :  2  or  3  pills  morning  and  evening,  before  eating. 

We  have  lately  tried  iodothyrin  (Baumann),  not  with- 
out success  (in  capsules  containing  1.0  (gr.  xv),  prepared 
with  sacchar.  lact). 

Tincture  of  iodin,  which  lias  occasionally  been  given 
in  drops  in  a  mucilaginous  decoction,  is  not  advisable  on 
account  of  the  gastric  disturbances  which  it  is  apt  to  pro- 
duce. 

Last  in  the  list  of  iodin  preparations  is  ferric  iodid  : 

I^.  Syrup,  ferri  iodid,  10.0  (sijss); 

Syrup,  cort.  aurant., 
Syrup,  simpl.,  da.      20.0  (sv) ; 

S. :  2  or  3  teaspoonfuls  a  day  for  adults ;   1  teaspoonful 
for  children. 

It  is  a  good  remedy,  either  by  itself  or  in  conjunction 
with  mercurial  preparations. 

Medicinal  "Woods. 

Decoctions  of  sarsaparilla,  lignum  guaiac,  etc.,  are 
to  be  regarded  as  simple  cathartics,  diuretics  and  sudo- 
rifics.  Those  which  contain  mercury  or  iodin,  like 
Decocfum  Zittinanni,  are  not  without  medicinal  qualities. 
The  latter  remedy  still  enjoys  a  certain  reputation.  Pre- 
scribe 200  to  300  (f  .Ivj  to  f  .?ix)  Zittinanni  Decoctum  for- 
tius, to  be  taken  warm  early  in  the  morning.  Decoctum 
Zittmanni  mitius  at  night  before  retiring,  usually  taken 
cold. 

If  these  remedies  are  used,  the  diet  must  be  strictly 
regulated.     Cheese,  salad,  fresh  fruit,  beer,  and  all  inflat- 


VENEREAL   ULCERS.  89 

ing  foods  are  to  be  avoided.  The  diet  should  consist 
principally  of  roasted  meats,  vegetables,  tea,  ham,  soft- 
boiled  eggs,  and  wheat  bread.  If  the  patient  lias  more 
than  four  stools  a  day,  the  drug  is  too  potent  and  the 
dose  must  be  reduced.  In  many  cases  Decoctum  Zitt- 
manni  is  used  with  advantage  as  an  adjunci;  to  the  in- 
unction cure. 

In  concluding  this  chapter  on  the  general  treatment,  let 
me  emphasize  once  more  that  the  patient  nmst  keep  his 
room  well  aired  and  well  heated,  and  in  the  mild  season 
must  spend  a  good  deal  of  time  in  the  open  air.  He 
must  have  plenty  of  good,  nutritious  food.  My  own 
experience  leads  me  to  condemn  all  starvation  or  dry- 
bread  "  cures,"  combined  with  sudorific  baths  and  other 
remedies  calculated  to  weaken  the  organism.  Although 
an  apparent  cure  may  sometimes  be  effected,  and  the 
symptoms  temporarily  subside,  the  treatment  is  of  no 
lasting  value ;  I  have  often  had  occasion  to  observe  grave 
relapses  within  a  very  short  time  after  such  "  cures." 

As  supplementary  cures  we  may  recommend  baths 
— sea-batlis,  hot  baths  containing  iodin  or  sulphur,  or  a  sys- 
tematic hydrotherapy,  which  is  so  effective  in  regulating 
various  morbid  conditions  and  tends  to  strengthen  and 
harden  the  patient. 

VENEREAL  ULCERS. 

It  is  now  generally  conceded  that  there  is  a  form  of 
ulcer  quite  distinct  from  the  initial  syphilitic  lesion  due  to 
infection  during  sexual  intercourse.  It  is  the  simple, 
venereal,  contagious,  non-indurative,  soft  ulcer,  the  so- 
called  soft  chancre. 

As  we  have  already  stated,  this  form  of  ulcer  may  be 
transmitted  at  the  same  time  with  syphilis,  but  it  also 
occurs  independently  and  has  its  own  peculiar  characters, 
both  as  regards  its  form  and  the  consequences  to  which  it 
gives  rise. 

The  seats  of  the  venereal  ulcers  are  the  external  skin 


90  THE  VENEREAL   DISEASES. 

and  the  mucous  membranes  of  the  genital  region  and, 
under  certain  conditions,  of  the  rest  of  the  body.  The 
specific  bacillus,  which  has  been  isolated  during  the  last 
few  years  (Ducrey-Krefting,  Unna-Krefting),  is  contained 
in  the  pus  and  in  the  tissues  of  the  ulcer.  It  gives  rise 
to  other  similar  ulcers  which  a])pear  in  series  in  the  same 
organism  and  constitute  a  purely  local  disease. 

The  ulcer  develops  almost  immediately  after  infection 
has  taken  place  through  an  abrasion  of  the  skin  or  mucous 
membrane ;  usually  within  twelve  to  twenty  hours,  in  ex- 
ceptional cases  after  thirty-six  to  seventy-two  hours.  The 
purulent  softening  is  at  first  circumscribed,  but  soon  shows 
a  tendency  to  spread,  both  downward  and  laterally,  by 
suppurative  destruction  of  the  skin.  When  mixed 
with  syphilitic  products  the  venereal  pus  constitutes  a 
virus  which  is  doubly  dangerous  to  the  non-syphilitic 
organism.  In  such  a  case  the  venereal  ulcer  develops 
within  a  very  short  time  and  is  followed  later  on  by  the 
appearance  in  the  same  situation  of  the  initial  syphilitic 
lesion  with  its  characteristic  infiltration  and  induration. 
In  a  syphilitic  individual  the  venereal  ulcer  shows  its 
usual  characters ;  although,  according  to  some  observers, 
the  inflammatory  reaction  is  aggravated  by  the  excessive 
irritability  inherent  in  all  syphilitic  tissues. 

The  ulcer  begins  as  a  pustule  resembling  acne ;  in 
twenty-four  hours  it  becomes  filled  with  pus  and  on  the 
following  day  it  bursts,  discharging  a  mass  of  thick  pus. 
The  ulcer  now  looks  as  if  it  had  been  cut  out  with  a 
punch,  it  has  sharply  defined  edges  and  is  surrounded  by 
a  narrow  zone  of  inflammation.  If  a  large  wound,  such 
as  results  from  laceration  for  instance,  becomes  infected 
with  venereal  pus,  the  resulting  ulcer  exhibits  a  purulent 
floor  wnth  sharp,  inflamed,  suppurating  Avails.  The  latter 
are  frequently  undermined  by  the  action  of  the  pus  and 
converted  into  detached  shreds,  more  or  less  swollen  and 
inflamed,  and  loosely  adherent  to  the  margin  of  the  ulcer. 
The  thick  pus  adheres  to  the  surrounding  surface  and 
produces  new  ulcers  which  rapidly  increase  in  size  and, 


VENEREAL    ULCERS.  91 

by  coalescing  with  the  original  ulcer  and  with  each  other, 
form  large,  irregular  ulcerating  areas.  If  the  pus  is 
carried  into  a  sebaceous  or  mucous  gland,  deej)  ulcers,  as 
large  as  a  pea  and  resembling  furuncula,  result.  The 
pus  is  discharged  through  the  duct  of  the  disintegrated 
follicle  some  time  before  the  walls  break  down,  and  a 
deep,  eroded  ulcer  is  exposed.  Ulcers  wliich  are  deep 
seated  from  the  beginning  frequently  simulate  an  indura- 
tion before  they  break  down  and  pus  is  discharged.  If 
the  inflamed  tissues  are  at  all  hyperplastic,  there  is  a  per- 
ceptible increase  in  the  resistance,  but  the  sore  never 
assumes  the  character  of  a  typical  syphilitic  sclerosis. 
Induration  is  always  a  relative  conception,  even  syphilitic 
ulcerations  sometimes  exhibit  but  a  slight  degree  of 
induj-ation.  The  rapid  development,  profuse  suppura- 
tion, spread  by  infection  to  the  surrounding  parts,  and 
the  slight  degree  of  induration  are,  however,  suffi- 
ciently cliaracteristic  to  establish  the  diagnosis  of  vene- 
real ulcer. 

The  course  is  very  simple  if  proper  treatment  is  used 
and  the  pus  can  be  removed.  Within  a  week  or  two 
the  floor  of  the  ulcer  ceases  to  secrete,  and  granulation- 
tissue  is  formed,  the  walls  are  reduced  to  the  level  of 
their  surroundings,  and  cicatrization  of  the  ulcer  begins 
from  one  side  or  the  other.  If  the  case  is  carefully 
treated,  the  resulting  scar  is  quite  soft  and  but  little  de- 
pressed below  the  level  of  the  skin.  Sometimes,  liow- 
ever,  owing  to  the  seat,  number,  and  extent  of  the  vene- 
real ulcers  and  to  numerous  external  conditions,  the 
course  as  well  as  the  termination  of  the  disease  is  more 
serious.  We  have  seen  venereal  ulcers  in  the  foreskin, 
in  the  skin  of  the  scrotum,  groin,  and  surface  of  the 
opposite  thigh,  separated  by  more  or  less  robust  bridges 
of  healthy  skin,  which  constituted  a  grave  condition. 
Under  such  circumstances  the  lymph-glands  in  the  neigh- 
borhood are  nearly  always  involved. 

Patients  whose  resisting  power  is  low,  or  those  who  are 
enfeebled  by  other  disease,  suffer  most  from  this  condi- 


92  THE   VENEREAL  DISEASES. 

tion,  as  they  lack  the  necessary  energy  to  care  for  the 
ulcers  properly  from  the  beginning. 

It  has  already  been  stated  that  the  genitalia  are  the 
most  frequent  seat  of  venereal  ulcers.  In  the  rna/e  the 
foreskin,  the  inner  layer  near  the  coronary  sulcus,  and 
particularly  the  frenum,  which  is  often  perforated  at  the 
base  and  reduced  to  a  slender  thread  connecting  the  fore- 
skin with  the  head  of  the  penis.  The  head  itself  is 
attacked  less  frequently,  possibly  because  it  contains 
fewer  gland-ducts  and  is  covered  Avith  smooth  epidermis. 
J71  the  female  the  most  frequent  sites  are  the  labia  majora, 
especially  the  posterior  commissure,  the  vaginal  orifice, 
and  the  remains  of  the  hymen  (fimbriae),  the  urethral 
orifice,  the  perineum,  anus,  vagina  and  vaginal  portion  of 
the  uterus. 

In  both  sexes  venereal  ulcers  are  often  found  in  the 
folds  of  the  groin,  on  the  inner  aspect  of  the  thighs,  and 
on  the  symphysis.  In  addition  we  may  mention  the 
nose,  mouth,  tongue,  nipple,  navel,  fingers,  and  other  dis- 
tant parts  covered  with  hair,  which  may  become  infected 
by  accidental  contact  with  the  purulent  secretions. 

If  the  above-mentioned  characters  are  borne  in  mind — 
the  circular  shape,  sharply  defined  edges,  rapid  develop- 
ment, and  multiplicity — venereal  ulcers  can  readily  be 
distinguished  from  other  processes  occurring  about  the 
genitalia,  such  as  acne,  furuncula,  etc.  If  there  is  no 
suspicion  of  sexual  intercourse  preceding  the  appearance 
of  such  processes,  the  diagnosis  is  quite  easy.  Moist 
papules  in  process  of  degeneration  or  covered  with  a 
diphtheritic  secretion  constitute  the  most  frequent  source 
of  error.  Again,  however,  the  nature  of  the  accompany- 
ing syphilitic  symptoms,  infiltration  of  neighboring 
lymph-glands,  lesions  of  the  skin  and  mucous  membranes, 
the  longer  duration  of  syphilitic  products,  and,  on  the 
other  hand,  the  suppuration  in  the  glands  which  usually 
accompanies  venereal  ulcers  of  long  standing,  afford  a 
protection   against  error  in   diagnosis  (Plates  61,   62). 

The  complications  which  occur  with  venereal  ulcers 


VENEREAL   ULCERS.  93 

are  chiefly  clue  to  the  rapidly  spreading  inflammation 
which  accompanies  the  ulceration. 

An  ulcer  situated  at  the  edge  of  the  foreskin  often 
produces  an  inflammatory  phimosis  or  paraphimosis.  In 
either  case  gangrene  may  develop  in  the  prepuce.  A 
deep  ulcer  may  produce  a  perforation  in  the  frenum  or 
even  into  the  urethra. 

One  of  the  most  unpleasant  complications  is  the  inflam- 
mation of  the  lymphatics  on  the  dorsum  penis ;  abscesses 
sometimes  result  and  the  skin  over  the  abscesses  is  very 
prone  to  become  gangrenous  [Bubonulus  Nisbethii).  If 
there  are  several  abscesses,  the  accumulated  venereal  pus 
under  the  skin  may  produce  troublesome  and  tedious 
complications  requiring  the  most  energetic  treatment 
(Plate  64). 

In  the  female  we  frequently  observe  ulcers  in  the 
shape  of  fissures  between  the  fimbriae,  deep  ulcers  in  the 
ducts  of  Bartholin's  glands,  and  destructive  ulcerations 
about  the  urethral  orifice,  part  of  which  is  sometimes 
entirely  lost  by  destruction  of  the  upper  wall.  The 
posterior  commissure  is  often  the  seat  of  large,  deep 
idcers,  dangerous  not  only  on  account  of  their  long  dura- 
tion, but  also  because  they  are  apt  to  spread  toward  the 
rectum. 

The  frequent  contamination  with  fecal  matter  and  the 
painful  stretching  to  which  the  parts  about  the  anus  are 
subjected  tend  to  aggravate  the  condition  in  that  situa- 
tion. The  pain  prevents  the  patient  from  fighting  the 
ulceration  as  vigorously  as  he  should,  so  that  it  often 
spreads  to  the  rectum. 

One  of  the  most  important  complications  of  the  soft 
chancre  is  found  in  the  inflammation  of  the  local  lymph- 
glands — bubo  or  adenitis. 

Adenitis  rarely  develops  within  the  first  two  weeks 
after  the  appearance  of  the  chancre ;  usually  it  does  not 
appear  until  the  third  or  fourth  week,  or  even  later;  in 
some  cases  the  glands  begin  to  become  inflamed  after  the 
ulcers  have  completely  healed.     This  is  apt  to  be  the  case 


94  THE   VENEREAL  DISEASES. 

when  the  ulcers  are  small  and  run  their  course  without 
being  noticed ;  it  is  not  possible  in  every  case  to  refer  the 
adenitis  to  the  presence  of  a  venereal  ulcer.  But  the 
statement  which  has  occasionally  been  made,  that  adenitis 
may  develop  without  either  the  presence  or  previous 
existence  of  a  venereal  ulcer,  through  the  uninjured  skin, 
is  not  supported  by  the  facts  (primary  buboes). 

The  nearest  group  of  lymph-glands  is  always  in  dan- 
ger of  becoming  involved,  whatever  may  be  the  seat  of 
the  ulcers ;  but,  as  they  are  most  frequently  found  in  or 
about  the  genitalia,  we  shall  confine  ourselves  in  the 
following  to  the  lymph-glands  of  the  inguinal  region. 

As  a  rule,  the  glands  of  the  same  side  are  affected  ;  but 
occasionally  the  glands  of  the  opposite  side  have  been  ob- 
served to  suppurate,  which  is  explained  by  the  anatomical 
arrangement  of  the  lymphatic  vessels  and  their  communi- 
cation with  each  other. 

One  or  more  glands  at  first  become  slightly  enlarged  ; 
as  the  swelling  and  pain  increase,  especially  if  the  part  is 
freely  used,  a  flat  tumor  with  inflamed  surface  appears. 
If  several  glands  are  affected  and  the  cellular  tissue  around 
them  becomes  swollen,  an  immovable  mass  of  varying  size 
develops,  completely  filling  the  inguinal  region.  Once 
the  swelling  has  reached  this  stage  there  is  little  hope  of 
resolution  ;  usually  the  tumor,  which  may  be  more  or  less 
prominent,  begins  to  fluctuate  and,  unless  surgical  aid  is 
rendered  at  once,  the  skin  softens  and  undergoes  liquefac- 
tion-necrosis. Sometimes  gangrene  supervenes,  and  the 
abscess  discharges  a  thin,  purulent  material  mixed  with 
detritus.  The  condition  is  very  painful  and  may  be  at- 
tended with  fever  and  marked  disturbances  of  the  general 
health ;  if  left  to  itself  after  the  contents  of  the  abscess 
have  been  discharged,  it  persists  for  a  long  time  until  the 
cavity  of  the  abscess  clears  up.  the  degenerated  superficial 
portion  is  cast  off',  and  scar-formation  begins.  In  rare 
cases  the  giingrene  spreads  to  such  an  extent  that  large 
areas  of  the  skin  and  subcutaneous  cellular  tissue  are 
destroyed,  exposing  the  muscles  of  the  inguinal  region 


VENEREAL    ULCERS.  95 

and  even  of  the  lower  abdomen,  as  if  they  had  been  dis- 
sected for  anatomical  demonstration.  Sometimes  a  multi- 
locular  adenitis  develops  by  the  accnmulation  of  pus  in 
one  spot  and  the  undermining  of  the  subcutaneous  tissue 
and  suppuration  of  the  nearest  gland.  The  day  after  one 
abscess  has  been  opened  another  appeal's  in  its  immediate 
proximity.  In  the  days  of  conservative  surgery  patients 
would  present  themselves  for  treatment  with  six  or  eight 
such  abscesses,  all  communicating  with  each  other  by 
fistulse  and  discharging  thin,  serous  pus  on  pressure. 
They  have  been  termed  strumous  buboes ;  they  contain 
enlarged  and  inflamed  glands  or  the  remains  of  glands 
embedded  in  a  stroma  of  connective  tissue  which  becomes 
very  robust  in  advanced  cases.  We  once  saw  such  a  case 
of  neglected  adenitis  which  resulted  in  putrefaction  and 
discharge  of  the  glands  in  the  iliac  region,  followed  by 
general  sepsis. 

The  diagnosis  of  such  inflammatory  tumors  in  the 
inguinal  region  can  scarcely  fail  to  be  made  if  the  rapid 
development  and  the  presence  of  ulcers,  or  at  least  scars 
at  the  periphery  (the  genitalia,  inner  surfaces  of  the 
thighs,  nates)  are  taken  into  consideration.  The  differen- 
tial diagnosis  from  scrofulous  glandular  abscesses,  although 
it  has  no  jjractical  value,  can  easily  be  made  by  the  gen- 
eral condition  and  the  presence  or  absence  of  scrofulous 
signs  in  the  skin  and  in  the  other  glands  of  the  body. 
Secondary  abscesses  from  tiie  pelvic  region  and  diffuse 
phlegmon  from  osteal  or  periosteal  disease  can  easily  be 
distinguished  by  the  nature  of  the  secretions,  the  dura- 
tion of  the  process,  and  by  careful  examination  into  the 
condition  of  the  bones  and  cartilages.  There  remain 
inguinal  and  femoral  hernias,  which  only  the  most  super- 
ficial examiner  could  mistake  for  adenitis.  It  is  to  be 
remembered,  however,  that  a  testicle  which  has  become 
confined  at  the  external  abdominal  ring  may  be  so  swollen 
and  inflamed  as  to  simulate  an  adenitis  (see  Plates  62,  63). 

The  adenitis  whicli  accomj)anies  the  primary  syphilitic 
lesion  has  been  treated  in  its  proper  place. 


96  THE  VENEREAL  DISEASES. 

Treatment  of  Venereal  Ulcers. — The  contagious 
material  is  contained  in  the  pus.  The  principal  part  of 
the  treatment  consists,  therefore,  in  removing  the  pus  and 
in  preventing  its  being  retained  within  the  ulcer  or  con- 
veyed to  surrounding  portions  of  the  skin. 

Cauterization,  on  account  of  its  rapidity  and  efficiency 
in  bringing  about  a  thorough  cure,  has  always  stood  in  high 
repute  as  a  treatment  for  venereal  ulcers.  Copper  salts, 
carbolic  acid,  ferric  chlorid,  nitrate  of  silver,  caustic  lime, 
(quicklime)  and  the  actual  cautery  itself  have  been  em- 
ployed. The  actual  cautery,  or  the  thermocautery  which 
now  takes  its  place,  is  still  the  sovereign  remedy.  Of  the 
others,  sulphate  of  copper,  in  a  solution  of  1  part  of  sulphate 
of  copper  to  4  parts  of  water  is  the  best,  as  it  cauterizes 
the  ulcer  and  the  surrounding  infiltrated  tissues  Avithout 
danger  of  injury  to  the  healthy  parts.  The  sulphate  of 
copper  is  to  be  applied  three  or  four  times  a  day  for  some 
time.  The  wound  is  treated  for  a  quarter  of  an  hour  at 
a  time  with  pledgets  of  cotton  dipped  in  the  solution,  the 
pledgets  being  changed  several  times.  Finally  a  pledget 
is  squeezed  dry  and  allowed  to  remain  on  the  ulcer. 
Cauterization  with  the  solid  stick  is  less  satisfactory  and 
more  painful.  The  swelling  which  follows  with  the  reac- 
tion must  be  controlled  with  compresses.  In  one  day  a 
dry,  bluish  eschar  is  formed  which  gradually  comes  away 
during  the  next  two  days.  A  dry,  anemic  wound  remains, 
after  which  granulation  and  cicatrization  must  be  induced 
by  other  means. 

Concentrated  carbolic  acid  has  a  similar  action  ;  it  is 
applied  with  a  cotton  pledget  fastened  to  the  end  of  a 
wooden  applicator  like  a  brush. 

Silver  nitrate,  like  copper  sulphate,  is  better  applied  in  a 
saturated  solution  tlian  with  the  solid  stick.  Vienna  paste  ^ 
and  chlorid  of  zinc  cannot  be  used  in  all  situations  on  ac- 
count of  the  danger  to  the  surrounding  parts. 

The  best  remedy  of  all  is  the  Paquelin  thermocautery. 

'  Caustic  potash,  5 ;  slaked  lime,  6,  mixed  with  alcohol  to  form  a 
paste. 


VENEREAL    ULCERS.  97 

Whatever  form  of  cauterization  be  used,  local  anesthesia 
should  first  be  induced  by  some  of  the  customary  drugs, 
cocain,  etc.  (If  the  Paquelin  thermocautery  is  used, 
ethyl  clilorid  must  not  be  employed.) 

If  the  seat  of  the  ulcer  is  such  that  cauterization  is  not 
practicable  (vaginal  orifice,  anus),  it  is  replaced  by  care- 
ful applications  of  dusting-powder,  ointments,  or  pastes, 
such  as  iodoform,  dermatol,  airol,  salicylic  acid,  xeroform, 
etc.  If  such  remedies  are  carefully  and  conscientiously 
applied,  a  few  days  will  suffice  to  convert  the  ulcers  into 
ordinary  granulating  wounds  (stadium  reparationis). 

In  cases  where  the  skin  becomes  undermined,  in  fistulas, 
in  perforations  of  the  frenum  of  the  labia,  the  abscesses 
are  first  carefully  disinfected  and  then  opened  with  the 
knife  and  converted  into  open,  granulating  wounds.  If, 
as  occasionally  haj)pens  in  venereal  ulcer,  gangrene  de- 
velops, a  line  of  demarcation  soon  forms,  the  ulcer  as 
such  is  destroyed,  and,  after  the  gangrenous  slough  is  cast 
off,  an  ordinary  wound  without  any  specific  character 
remains. 

The  phagedenic  ulcer  is  nothing  but  a  rare  subvariety 
of  gangrene,  with  a  tendency  to  rapid,  purulent  liquefac- 
tion. Such  ulcers  spread  rapidly,  have  thick,  irregular 
edges,  and  bleed  very  easily.  The  floor  is  covered  with 
a  dirty  yellowish  material ;  the  surroimding  tissue  is  in- 
flamed and  of  a  pale-red  color.  It  is  difficult  to  deter- 
mine the  cause  of  phagedenic  ulcers ;  they  usually  occur 
in  neglected  cases,  in  anemic,  debilitated  individuals.  The 
best  treatment  is  the  thermocautery,  used  under  anesthesia. 

Treatment  of  the  Adenitis. — The  treatment  of  vene- 
real inflammation  and  abscess-formation  in  the  glands 
varies  somewhat  for  each  individual  case,  hence  we  can 
give  only  a  few  general  guiding  principles. 

Since  most  c<ises  of  adenitis  are  not  due  to  infection  by 
the  venereal  pus  which  contains  the  virus,  but  represent 
simply  a  form  of  symj)tomatic  buboes,  the  effect  of  rest 
and  the  application  of  moderately  cold  compresses  of 
aluminum  acetate  solution,  supplemented  by  an  ice-bag 

7 


98  THE   VENEREAL  DISEASES. 

on  the  outside,  should  first  be  tried.  The  time-honored 
remedy  of  painting  with  tincture  of  iodin  and  galls  occa- 
sionally produces  good  results ;  we  do  not,  however,  recom- 
mend a  mere  trial  application  of  the  tincture,  as  it  only 
produces  blisters  and  increases  the  pain.  To  have  any 
effect  the  painting  must  be  thorough  ;  then  a  scab  will 
be  formed  on  the  same  day  and  the  progress  of  the  inflam- 
mation will  thus  be  arrested.  If  an  abscess  forms  in  spite 
of  such  energetic  treatment,  immediate  interference  is  in- 
dicated. The  mildest  treatment  of  adenitis  consists  in 
])uncture,  evacuation  of  the  abscess,  and  irrigation  of  the 
cavity  with  a  1  per  cent,  solution  of  argentic  nitrate,  the 
wound  being  afterward  dressed  with  iodoform  oi'  sterilized 
gauze  and  the  dressing  held  in  place  with  a  spica  bandage. 
The  dressing  is  changed  the  next  day.  If  the  secretion  is 
still  purulent,  the  abscess  is  again  irrigated.  After  two 
days  the  dressing  is  again  changed,  and  so  on  as  long  as 
the  indications  continue. 

If  the  abscesses  are  large  and  boggy  and  covered  with 
a  thin  layer  of  skin,  or  if  the  roof  has  become  gangrenous 
and  the  abscess  bursts,  the  surrounding  parts  are  first 
thoroughly  cleansed,  after  which  the  hair  is  shaved,  and 
the  skin  is  again  washed  with  ether  and  alcohol  and 
irrigated  with  a  lukewarm  solution  of  sublimate.  The 
attenuated  covering  is  then  removed,  and  the  liquefied 
remains  of  glands  and  capsule,  as  well  as  the  pur-ulent 
inflammatory  tissue  between  the  glands,  scraped  out  by 
one  of  the  many  methods  known  to  modern  surgery. 
This  is  the  quickest  way  to  effect  a  cure.  The  dressing 
can  be  left  on  for  several  days,  to  give  the  patient  a 
chance  to  recover  from  the  pain  and  shock  of  the  ope- 
ration. 

The  first-mentioned  treatment  for  adenitis  requires  from 
ten  days  to  three  weeks  to  effect  a  cure ;  the  second,  owing 
to  the  gravity  of  the  cases  in  which  it  is  employed,  from 
five  to  eight  weeks. 


VENEREAL    ULCERS.  99 

Solutions  for  External  Use. 

^.  Hydrarg.  chlor.  corros.,  0.5  (.5Jss) ; 

Spirit,  vin., 

Aq.  dest.,  da.  100.0  (f.liij). 

S.  :  Dilute  in  5  times  the  quantity  of  water. 
To  be  used  as  a  lotion,  with  cotton  pledgets. 

Iji.  Acid,  carbol.,  4.0  (,^j)  ; 

Spirit,  vin.,  40.0  (f^x)  ; 

Aq.  dest.,  160.0  (f^v). 
S. :  External  use. 

^.  Sodii  borat.,  10  to  200. 

S. :  Lotion. 

i;^.  Acid,  salicy].,  2-4  to  200. 

S. :  As  above. 

I^.  Cupr.  sulpha t.,  1  to  5. 

S. :  For  cauterization. 

I^.  Cupr.  sulphat.,  2-5  to  100.    - 

S. :  To  be  used  in  washing  ulcers  on  the  penis,  pre- 
puce, etc.,  for  from  5  to  10  minutes,  and  for 
dressing. 

Dusting-powders,  to  be  used  after  the  ulcers  have  been 
cleansed  with  the  aboved-named  solutions  : 

I^.  Iodoform,  pulv.,  10.0  (sijss). 

S. :  Dusting-powder. 

I^.  Iodoform,  1  to  5. 

With  ether  sulph. 
S. :  For  spraying. 

I^.  Iodoform,  1  to  5  ; 

Vaselin. 
S. :  Ointment.     To  be  applied  to  the  wound  with  gauze. 

IB^.  Iodoform  gauze,  20  per  cent. 

S. :  For  bandaging. 


100  THE   VENEREAL  DISEASES. 

^.  Xeroform.  pur.,  10.0  (sijss). 

S. :  Dusting-powder. 

^.  Dermatol,  pulv.,  10.0  (sijss). 

S. :  As  above. 

I^.  Aristol. 
S. :  As  above. 

'Bf,.  Airol. 

S. :  As  above. 

I^.  Hydrarg.  ammoniat.,        0.5  (gr.  viij) ; 
Vaselin,  15.0  (3Jv). 

S. :  Ointment  for  dressing. 

ISf.  Hydrarg.  oxid.  rubr.,         0.1  (gr.  jss)  ; 
Vaselin,  10.0  (sijss). 

S. :  Ointment  for  dressing  torpid  ulcers. 

^.  Arg.  nitr.  fus. 
S. :  For  touching  proliferating  ulcers  after   the   use   of 
iodoform  and  other  remedies. 

I^.  Arg.  nitr.,  1  to  15. 

S. :  To  be  applied  with  pledgets  of  cotton  instead  of  the 
solid  stick. 

'Sf.  Bitum.  phag.  5.0  (3Jss)  ; 

Gyps,  (selenite,  a  native 

sulphate  of  calcium),    30.0  (Ij). 
S. :  Powdered  gypsum.    For  extensive  gangrenous  wounds 
and  neglected  ulcers. 


GONORRHEA. 

Gonorrhea,  or  blennorrhea,  is  usually  localized  in  the 
mucous  membrane  of  the  genitalia.  In  the  majority  of 
cases  infection  takes  place  by  direct  contact ;  it  may, 
however,  be  conveyed  indirectly  by  polluted  instruments, 
specula,  clothing,  bandages,  towels,  etc. 


GONORRHEA.  101 

The  cause  of  this  form  of  venereal  catarrh  is  the 
gonococcus  of  Neisser,  which  lias  been  demonstrated  in 
the  secretions,  in  the  affected  mucous  membranes,  and 
in  other  tissues,  glands,  and  submucous  tissues  involved  in 
the  process. 

The  results  of  numerous  observations  have  established 
the  fact  that  many  other  micro-organisms,  M'hose  special 
characters  have  not  as  yet  been  accurately  described,  exist 
normally  and  pathologically  in  the  mucous  membrane  of 
the  genitalia.  In  addition  to  the  specific  gonorrhea  pro- 
duced by  the  gonococcus  of  Neisser,  there  are  other  catar- 
rhal affections  of  the  genital  mucous  membrane  in  which 
these  micro-organisms  are  also  found. 

The  limited  scope  of  this  work  forbids  a  more  detailed 
discussion  of  these  conditions,  and  for  the  same  reason 
our  description  of  the  gonorrheal  processes  themselves  is 
perforce  very  brief  and  synoptic. 

It  is  a  matter  of  clinical  experience  that  contact  of 
a  healthy  with  a  gonorrheal  mucous  membrane  produces 
in  from  a  few  hours  to  three  days  alterations  which  sug- 
gest the  probability,  if  not  the  certainty  of  the  infectious 
nature  of  gonorrhea. 

The  symptoms  consist  of  inflammation  and  hyper- 
emia of  tiie  affected  mucous  membrane,  coupled  with  a 
discharge,  at  first  mucous,  but  rapidly  becoming  purulent. 
The  patient  himself  early  becomes  aware  of  the  condi- 
tion on  .account  of  the  swelling  and  subjective  sense  of 
burning.  Gonorrhea  is  distinguished  from  all  other  forms 
of  catarrh  in  the  genital  mucous  membranes  by  its  rapid 
spread  and  by  the  intense  inflammation  which  marks  the 
first  week  of  its  course. 

Acute  urethral  gonorrhea  in  the  male  (urethritis 
blenorrhagica)  begins  with  a  burning  sensation,  felt  most 
during  micturition ;  the  member  is  in  a  condition  of 
semi-erection,  the  urethra  itself  is  more  or  less  increased 
in  thickness  and  discharges  at  first  a  thin,  watery  pus, 
which  later  becomes  thick  and  creamy,  and  in  severe 
cases  even  mixed  with  blood. 


102  THE  VENEREAL  DISEASES. 

If  the  patient  is  so  careless  as  to  neglect  this  condition, 
the  gonorrheal  inflammation  spreads  to  the  membranous 
and  prostatic  portions  of  the  urethra  and  eventually  to 
the  neck  of  the  bladder,  although  there  may  be  at  first  a 
partial  abatement  of  the  inflammatory  and  subjective 
symptoms. 

The  intensity  of  the  subjective  symptoms  increases 
with  the  spread  and  severity  of  tlie  gonorrhea,  the  patient 
complains  of  pressure  in  the  perineum  and  feels  a  con- 
stant desire  to  urinate  [tenesmus)  and,  if  the  neck  of  the 
bladder  is  involved,  is  forced  to  urinate  at  intervals  of 
half  an  hour  to  an  hour.  The  inflammation  itself  and 
the  pain  which  it  produces,  and  which  usually  becomes 
worse  at  night,  are  sometimes  very  violent,  so  that  the 
most  phlegmatic  individuals  find  them  very  distressing. 

No  difficulty  is  experienced  in  demonstrating  the  char- 
acteristic gonococci  within  the  cells  of  the  urethral  secre- 
tion in  any  stage  of  the  disease.  Method :  spread  a 
minute  quantity  of  the  secretion  on  a  cover-slip,  allow  it 
to  dry,  and  pass  it  rapidly  through  the  flame  of  an  alco- 
hol lamp  two  or  three  times  (dry  and  fix),  stain  with  car- 
bol  fuchsin,  gentian-violet,  methyl-blue,  etc.,  wash  in 
water,  dry  with  bibulous  paper,  and  mount  in  Canada 
balsam.  The  gonococci  are  decolorized  by  Gram's  method. 
Demonstration  by  means  of  cultures  will  not  be  discussed 
at  this  point. 

If  the  secretion  is  copious,  the  urine  is  turbid  from 
admixture  of  pus  and  desquamated  epithelium,  which  col- 
lect at  the  bottom  of  the  vessel  and  form  a  dust-colored 
sediment.  In  order  to  diagnose  a  posterior  urethritis,  it 
is  advisable  to  direct  the  patient  to  collect  his  morning 
urine  in  two  separate  portions.  If  the  posterior  part  of 
the  urethra  is  involved,  both  portions  will  be  turbid. 

After  a  time  both  secretion  and  desquamation  of  the 
mucous  membrane  diminish.  Either  the  process  dis- 
appears from  parts  of  the  tube,  or  the  secretion  every- 
where diminishes  in  quantity  ;  at  all  events  there  is  only 
a   scant    discharge   of   creamy,   whitish    material   from 


GONORRHEA.  103 

the  urethra.  In  this  stage  of  the  disease  the  disoharge 
as  every  one  knows,  is  most  abundant  after  a  night's  rest ; 
tlie  patient  upon  rising  finds  the  opening  of  the  urethra 
ok)gged,  and,  on  squeezing,  more  or  less  pus  is  forced  out 
(goutte  militaire).  The  urine  contains  the  characteristic 
gonorrheal  shreds  consisting  of  mucus,  leukocytes,  and  epi- 
thelial cells  from  the  urethra.  At  the  same  time  there  is  an 
abatement  in  the  subjective  symptoms  ;  the  patient  feels 
much  better  and  his  complaint  is  less  troublesome.  Exces- 
sive indulgence  in  the  pleasures  of  Bacchus  or  Venus  at  this 
period  of  chronic  gonorrhea  may  bring  on  an  acute 
exacerbation  which  may  closely  simulate  a  fresh  infec- 
tion. 

The  gonorrheal  process  may  penetrate  the  mucous  mem- 
brane and  attack  the  submucosa,  or,  more  frequently, 
spread  along  the  ducts  which  empty  into  the  urethra  and 
involve  the  urethral  (/lands  themselves.  The  urethra  be- 
comes studded  with  nodular  outgrowths,  irregularly  dis- 
posed along  its  course,  which  may  persist  for  some  time, 
or  break  down  and  form  periurethral  abscesses.  The 
inflammation  in  the  submucosa  sometimes  spreads  to  the 
corpus  cavemosum,  where  it  produces  tumors  as  large  as, 
or  larger  than  a  walnut ;  if  the  inflammation  does  not 
subside,  large  abscesses  result.  The  symptoms  of  such 
an  acute  peri-urethritis  are  very  marked  :  pain,  fever, 
swelling,  and  distortion  (bending)  of  the  penis  and  fluc- 
tuation. 

Notwithstanding  the  great  lengths  of  their  ducts  Cow- 
per's  glands  are  also  invaded  by  the  gonorrheal  process. 
The  swelling  begins  behind  and  at  the  side  of  the  bulb 
of  the  urethra,  and  is  attended  with  moderate  ])ain  in  the 
perineum  ;  with  proper  care  on  the  part  of  the  patient 
the  swelling  may  disiippear  spontaneously.  As,  however, 
the  causes  which  originally  produced  the  inflammation  in 
the  glands,  such  as  forced  irrigation,  bougies,  dancing, 
riding,  and  driving,  do  not,  as  a  rule,  cease  immediately, 
the  inflammation  usually  continues  for  some  time.  A 
large,  painful,  fluctuating  tumor  soon  develops  in  the  peri- 


104  Tin:   VENEREAL  DISEASES. 

neuin.  The  patient  lias  high  fever  and  sometimes  chills. 
The  abscess  will  burst  of  its  own  accord  ;  but  it  is  better 
not  to  wait  for  that  event,  as  large  quantities  of  gas  and 
pus  often  accumulate  in  the  cavity  of  the  abscess  and 
undermine  the  entire  perineum  as  far  as  the  anus.  A 
speedy  cure  is  affected  by  opening  the  abscess  early  ;  large 
abscesses  take  from  two  to  three  months  to  heal  and  usu- 
ally leave  a  distortion  of  the  urethra. 

The  evil  effects  of  gonorrhea  show  themselves  much 
more  frequently  in  the  prostate  gland  than  in  any  of  the 
glandular  structures  which  have  been  mentioned.  Acute 
gonorrheal  prostatitis  constitutes  a  very  grave  complica- 
tion ;  the  patients  are  feverish,  complain  of  difficulty  in 
urination  and  defecation  (dysuria  and  tenesmus),  and  con- 
stant burning  pain  in  the  rectum.  On  palpation  per  rec- 
tum one  or  both  lobes  of  the  prostate  are  found  to  be 
swollen,  hard,  and  very  sensitive  to  pressure.  If  the  pro- 
cess goes  on  to  suppuration,  the  accumulated  pus  can 
sometimes  be  felt  as  a  soft  mass  within  the  swollen  paren- 
chyma. In  most  cases  it  is  discharged  spontaneously 
through  the  urethra  and  leaves  a  flattened  area  in  the 
prostate  which  can  be  distinctly  felt.  Sometimes  the 
swelling  does  not  suppurate,  but  results  instead  in  a  per- 
manent enlargement  of  the  prostate.  This  is  a  very  fre- 
quent concomitant  of  chronic  gonorrhea,  and  may  last 
as  long  as  the  patient  lives,  without  his  ever  being  aware 
of  it. 

Another  complication  which  is  often  overlooked  by  the 
patient  is  disease  of  the  seminal  vesicles.  It  may  occur 
independently  and  run  its  course  without  being  detected, 
or  it  may  be  accompanied  by  inflammation  of  the  pros- 
tate and  of  the  epididymis. 

The  most  frequent  complication  of  all  is  gonorrheal  epi- 
didymitis. It  makes  its  appearance  in  the  third  week  of 
the  disease.  Usually  it  is  unilateral,  but  it  may  affect 
both  sides,  either  simultaneously  or  one  after  the  other. 
The  testicle,  which  is  partially  enclosed  in  the  epididymis, 
becomes  swollen  and  painful.     The  spermatic  cord,  con- 


GONORRHEA.  105 

taining  the  blood-vessels  and  the  vas  deferens,  become  as 
large  as  a  finger  and  can  be  felt  as  high  np  as  the  inguinal 
canal.  The  condition  may  be  very  painful  and  attended 
with  high  fever,  so  that  tiie  least  susceptible  patients  are 
compelled  to  take  to  their  beds.  With  antiphlogistic 
treatment  and  complete  rest  the  pain  and  fever  disappear 
in  from  five  to  eight  days,  leaving  a  moderate  swelling 
and  more  or  less  induration  of  the  epididymis,  which  sub- 
sides in  from  four  to  five  weeks.  The  scrotum  is  always  in- 
volved in  the  inflammatory  process  and  adheres  to  the  swoll- 
en epididymis,  l)ut  usually  only  at  the  inferior  pole  on  the 
aifected  side.  In  some  cases  of  epididymitis  there  is  quite 
a  marked  exudation  into  the  tunica  vaginalis  propria  {acute 
hydrocele),  the  pressure  from  Avhich  causes  great  pain. 
The  exudate  is  sometimes  so  copious  that  it  can  be  seen 
through  the  superficial  layers  of  the  scrotum  at  the  supe- 
rior pole,  as  in  clironic  hydrocele. 

In  rare  instances  the  inflammation  extends  to  the  in- 
vesting membrane  of  the  testicles ;  tlie  parenchyma  of 
the  glands  themselves  becoming  involved  during  the 
inflammatory  stage  of  the  disease  only.  A  very  few  of 
the  many  cases  we  have  seen  resulted  in  contraction  of 
the  connective  tissue  and  atrophv  of  the  gland-substance 
itself. 

In  the  female  gonorrhea  is  more  apt  to  involve  the 
entire  genito-urinary  tract  than  in  the  male.  Ignorance 
of  the  nature  and  significance  of  the  disease  on  the  part 
of  the  patients  is  largely  responsible  for  this.  The 
patients  neglect  to  consult  a  physician,  either  because 
they  do  not  realize  the  gravity  of  their  condition  or  be- 
cause they  dread  exposure.  The  primary  seat  is  the 
mucous  membrane  of  the  vulva,  vagina,  and  urethra, 
which  becomes  inflamed  and  discharges  a  viscous,  puru- 
lent secretion.  The  patient  complains  of  burning  pain 
during  micturition.  The  inflammation  soon  attacks  the 
labia ;  intertrigo  and  eczema  develop  in  the  skin  and  ag- 
gravate the  burning  and  itching,  or  even  cause  actual 
pain.     If  treatment  is  still  delayed,  the  gonorrheal  ])Y0- 


106  THE  VENEREAL  DISEASES. 

cess  soon  produces  acute  endometritis,  salpingitis,  peri- 
metritis, oophoritis,  and  even  peritonitis.  In  this  way 
chronic  gonorrheal  conditions  frequently  develop,  having 
their  principal  seat  in  the  uterine  cavity  and  extending  in 
both  directions  at  the  least  exacerbation  of  tlie  process. 
The  patients  are  tortured  by  fever  and  various  kinds  of 
pain,  varying  according  to  the  seat  of  the  inflammation  ; 
pains  in  the  loNver  abdomen,  dragging  pains  in  the  back 
and  lumbar  region,  pains  before  menstruation,  etc. 

Gonorrheal  cystitis  and  pyelitis  are  very  rare  even  in 
protracted  cases  of  gonorrhea,  although  urethritis  is  both 
common  and  persistent.  They  are  certainly  much  less 
frequent  than  in  the  male,  Avhere  these  complications  con- 
stitute the  most  obstinate  and,  in  their  consequences,  often 
the  most  serious  sequelse. 

The  complications  discussed  so  far  may  be  regarded  as 
the  direct  extensions  of  the  gonorrheal  process.  Of  late 
years,  however,  numerous  clinical  observations  and  dis- 
coveries in  bacteriology  have  demonstrated  the  occurrence 
of  a  metastasis  of  gonococci ;  that  is,  an  extension  to  re- 
mote organs  by  way  of  the  blood-  and  lymph-channels. 
The  most  frequent  of  these  complications  is  gonorrheal 
rheumatism.  Usually  the  disease  attacks  but  one  joint 
(the  knee) ;  occasionally,  however,  several  joints  are  in- 
volved at  the  same  time.  The  cavity  of  the  aifected  joint 
becomes  filled  with  a  serous  exudate  and  considerably 
swollen  ;  there  is  a  moderate  rise  in  the  temperature  and 
a  good  deal  of  pain.  The  patient  keeps  the  affected  joint 
rigidly  fixed,  and  is  usually  confined  to  his  bed  for  some 
time  in  consequence. 

The  joint-affection  is  sometimes  combined  with  a  teno- 
synovitis, or  the  latter  may  occur  independently.  The 
inflammation  of  the  sheatli  is  characterized  by  swelling, 
redness,  and  considerable  pain  in  the  affected  tendons,  the 
extremities  involved  being  for  the  time  disabled. 

The  two  last-named  processes  are  very  painful  while 
they  last,  and  interfere  with  the  use  of  the  extremities  for 


GONORRHEA.  107 

some  time ;  they  usually  heal,  however,  without  leaving 
any  permanent  alterations. 

Diseases  of  internal  organs,  such  as  endocarditis  or 
pleuritis,  as  the  direct  consequences  of  gonorrhea  are  ex- 
ti'emely  rare.  On  this  account  and  because  they  so 
closely  resemble  diseases  which  depend  on  entirely  dif- 
ferent etiological  factors  the  diagnosis  is  very  difficult ; 
after  every  other  possibility  has  been  excluded  a  pre- 
sumptive diagnosis  may  be  made,  if  a  gonorrheal  condi- 
tion exists. 

The  mucous  membrane  of  the  rectum  often  becomes  in- 
volved in  the  gonorrheal  process,  especially  in  female 
patients,  either  by  the  gonorrheal  pus  dripping  down 
from  the  vagina,  or  by  direct  infection  through  accidental 
contact  with  the  penis  during  sexual  intercourse.  When 
gonorrhea  attacks  the  rectum  it  is  even  more  distressing 
and  painful  than  when  it  is  confined  to  the  genitalis. 
Defecation  is  difiicult  and  painful.  The  constiint  burning 
pain  is  so  intense  that  the  patients  are  as  restless  and 
excitable  as  if  they  were  sulfering  from  a  severe  illness. 
A  purulent  discharge  mixed  with  blood  and  the  remains 
of  the  broken-down  mucous  membrane  flows  from  the 
anus.  Energetic  treatment  is  required ;  the  condition 
often  lasts  for  weeks  and  may  result  in  extensive  cica- 
tricial contractions  of  the  rectum. 

Condylomata  Acuminata. 

Gonorrheal  warts,  venereal  papillomata,  must  be  men- 
tioned among  the  sequela  of  gonorrhea.  Althougli  it  is 
not  definitely  known  that  the  gonorrheal  virus  in  itself  is 
capable  of  producing  these  papillomatous  growths,  their 
frequent  occurrence  in  old,  and  even  in  acute  cases  of 
gonorrhea  justifies  the  assum])tion  that  they  are  chiefly 
due  to  the  constant  irritation  of  the  mucous  membrane 
and  external  skin  by  the  gonorrheal  secretion.  At  first 
the  surface  of  the  mucous  membrane  j^resents  a  scarcely 
perceptible  roughening,  resembling  ])lush  or  the  surface 


108  THE   VENEREAL  DISEASES. 

of  a  well-trirnnied  lawn.  The  process  begins  by  a 
lengthening  and  swelling  of  the  papillae.  As  the  con- 
dylomata develop,  the  capillary  loops  in  the  papillae  be- 
come longer  and  engorged  with  blood,  and  snrrounded  by 
a  moderate  round-celled  infiltration.  But  the  most  con- 
spicuous changes  are  observed  in  the  Malj)ighian  layer, 
the  greatly  proliferated  epithelium  of  which  covers  over 
the  papillae  and  fills  the  intervals  between  them  in  thick 
layers.  Owing  to  the  constant  maceration,  the  cells  of 
the  epidermis  do  not  become  horny,  but  undergo  desqua- 
mation, so  that  the  Malpighian  layer  is  practically  laid 
bare.  At  this  stage  the  surface  of  the  condylomata  is 
moist  and  greasy  to  the  touch.  But  the  process  is  rarely 
limited  to  this  cell-proliferation  ;  usually  groups  of  swol- 
len papillae  unite  to  form  tumors  as  large  as  a  pea  or  a 
hazelnut,  rising  from  the  base  of  the  skin.  Extensive 
growths  of  this  kind  present  the  appearance  of  cauli- 
flower, from  the  coalition  of  numerous  papillomata ;  the 
surface  is  ragged  and  deeply  furrowed.  The  degener- 
ating epithelium  and  the  whole  mass  of  purulent  material 
cause  the  patient  much  annoyance  both  on  account  of  the 
offensive  odor  and  the  copious  secretion.  The  capillary 
loops  in  the  papillae  are  easily  injured,  so  that  the  blood 
oozes  out  of  the  fissures  between  the  papillomata  if  the 
tumor  is  subjected  to  any  injury. 

In  the  male  the  condylomata  occur  most  frequently 
on  the  inner  surface  of  the  foreskin,  in  the  neck,  and  on 
the  glans  penis  at  the  urethral  orifice  and  sometimes  as 
high  up  as  the  fossa  navicularis.  Large  proliferations  in 
the  preputial  sac  may  by  their  pressure  jiroduce  inflam- 
mation and  even  necrosis  of  the  foreskin.  If  the  pro- 
liferations are  very  extensive,  the  differential  diagnosis 
from  carcinoma  is  often  difficult ;  it  is  based  on  the  dura- 
tion of  the  process,  the  presence  or  absence  of  isolated 
papillomata  near  the  periphery  of  the  larger  tumors  and 
on  the  condition  of  the  inguinal  glands. 

Condylomata  acuminata  are  more  frequent  in  the  fe- 
male.    The  vestibule,  orifice  of  the  urethra,  vagina,  and 


GONORRHEA.  109 

even  the  vaginal  portion  of  the  uterus  are  often  covered 
with  numerous  proliferations,  which  by  their  rapid  growth 
greatly  annoy  both  patient  and  doctor.  In  addition  the 
external  skin  of  the  female  genitalia  as  far  as  the  groin, 
and  the  perineum  and  region  about  the  anus,  may  be  the 
seat  of  such  venereal  papillomata;  we  have  even  seen 
tumors  as  large  as  the  list  occupying  this  entire  region. 

TREATMENT  OF  GONORRHEA  AND  ITS  COMPLICATIONS. 

Acute  Gonorrhea. 

During  the  stage  of  profuse  purulent  secretion  the  fol- 
lowing remedies  are  employed : 
{a)  Internal. — 

'Bf,.  Mass.  copaib.,  gtt.  x. 

Dent.  tal.  dos.  ad  caps,  gelatin.,  No.  1. 
S. :  4-6  capsules  daily. 

I^.  Ol.  santali,  gtt.  x. 

Dent.  tal.  dos.  ad  caps,  gelatin.,  No.  1. 
S. :  5-8  capsules  daily. 

IJi.  Pulv.  cubeb., 

Extr.  cubeb.  alcohol.,  aa  5.00  3jss. — M. 

Ft.  pil.  No.  1. 

Consperge  pulv.  glycyrrhiz. 
S.  :  3  pills  3  times  a  day. 

^.  Pulv.  cubeb.,  30.^  (§j)  ; 

Extr.  acori  calami, 

Extr.  gentian.,  dci    1.00  (gr.  xv). — M. 

S. :  One  knife-point  after  eating,  3  times  a  day. 

(6)  For  Injection. — During  this  period  remedies  are 
■employed  which  are  supposed,  or  known  to  possess  disin- 
fectant and  bactericidal  qualities,  but  no  astringent  eflFect 
on  the  mucous  membranes. 

^.  Amnion,  sulphoichthyol.,    1.5—2.00  (gr.  xxiv-3ss); 

Aq.  destill.,  100.00  (fsiij). 

S. :  To  be  injected  4  times  a  day. 


110  THE   VENEREAL  DISEASES. 

^.  Argonin,  1.00-2.00  (gr.  xv-3ss); 

Aq.  destill.,  100.00  (tgiij).— M. 

S.  :  To  be  injected  4  times  a  day. 

T^.  Acid,  tartar.,  2  :  100. 

S.  :  To  be  injected  2  or  3  times  a  day  ;  retain  for  10 
minutes. 

I^.  Potass,  hypermang.,  0.01  (gr.  ^)  ; 

Aq.  destill.,  100.00  (fgiij).— M. 

S.  :  To  be  injected  4  times  a  day. 

^.  Acid,  boric,  2.00-4.00  (3ss-3j) ; 

Aq.  destill.,       _  100.00  (fliiij).— M. 

S.  :  To  be  injected  4  times  a  day. 

At  the  end  of  the  second,  or  the  beginning  of  the  third 
week  astringents  are  employed. 

We  recommend  : 

^.  Zinci  sulphat.,  0.1-0.3  (gr.  jss-gr.  v); 

Aq:  destill.,  100.00  (f^iij).— M. 

S.  :  To  be  injected  4  times  a  day. 

I^.  Zinci  snlphocarbol.,       1.00-3.0  (gr.  xv-gr.  xlv); 

Aq.  destill,  200.00  (f^vj).— M. 

S.  :  To  be  injected  4  times  a  day. 

I^.  Arg.  nitr.,  0.10-0.50  (gr.  jss-viij) ; 

•   Aq.  destill.,  200.00  (fgvj).— M. 

S. :  To  be  injected  4  times  a  day. 

^t.  Zinci  sozoiodol.,         1.00-5.00  (gr.  xv-^ss); 
Aq.  destill.,  200.00  (fgvj).— M. 

S. :  To  be  injected  4  times  a  day. 

I|i.  Zinci  sulphat.,  0.5  (gr.  viij); 

Plumb,  acetat.,  1.00  (gr.  xv)  ; 

Aq.  destill.,  200.00  (fgvj).— M. 

S. :  To  be  injected  4  times  a  day.     Shake  before  using. 


GONORRHEA.  Ill 

R.  Bismuth,  siibnitr.,  5.00  (.^jss)  ; 

Aq.  destill.,  200.00  (f§vj).— M. 

S. :  To  be  injected  4  times  a  day.     Shake  before  using. 

Chronic  Gonorrhea. 

Injections  of  |^  to  2  per  cent,  solutions  of  argentic 
nitrate,  using  Guyon's  or  Ultzmann's  syringe.  As  high 
as  5  per  cent,  solutions  of  argentic  nitrate  are  used  for 
astringents. 

In  addition,  the  posterior  portion  of  the  urethra,  in  the 
male,  is  to  be  irrigated  with  the  lotions  given  for  acute 
gonorrhea,  using  a  N4laton  catheter  or  Ultzmann's  irriga- 
tion catheter. 

Inflammation  of  the  Neck  of  the  Bladder  (Cystitis 
Colli  Vesicae). 

The  patient  must  remain  in  bed ;  the  bowels  must  be 
kept  open  and  the  diet  regulated. 
Internally  : 

I^.  Folior.  uvse  ursi ; 

Herniarise  glabrae,  ad  25.00  (svjss). 

S. :  Tea. 

I^.  Decoct,  sem.  lini,  200.00  iHv])', 

Extr.  laudani,  0.10  (gr.  jss). 

S. :  Take  one  tablespoonful. 

Bf.  Salol,  ^  10.00  (3ijss) ; 

Div.  in  dos.  sequales,  No.  x. 
S. :  4  powders  daily. 

^.  Terebinth,  lig. ; 
Extr.  cinchonae ; 

Magnes.  carb.,  da  5.0  (3J8s) ; 

Extr.  et  pulv.  acori  calami,  ad  q.  s. ; 

F.  pil.  pond.,  0.20  (gr.  iij) ; 

No.  c,  consperge  pulv.  aromat. 
S. :  6-8  pills  a  day. 


112  THE   VENEREAL  DISEASES. 

Prostatitis. 

In  the  acute  form  lukewarm  sitz-baths  and  applications 
of  Arzberg's  apparatus,  either  exclusively  or  alternating 
with  suppositories : 

^i.  Morph.  muriat.,  0.10  (gr.  jss) ; 

Olei  theobr.  q.  s.  u.  f.  suppos.,  No.  x. 

^.  Extr.  opii  aquosi,  0.03  (gr.  ^)  ; 

Olei  theobr.,  3.0  (gr.  xlv)  ; 

F.  suppos.  div.  dos.  vi. 
S. :  Suppositories. 

^i.  Extr.  bellad., .  0.10  (gr.  jss) ; 

Olei  theobromse  q.  s.  u.  f.  suppos.,  No.  x. 

If  there  is  fluctuation,  the  abscess  is  opened  from  the 
rectum,  using  the  proper  surgical  precautions. 

In  chronie  prostatitis  suppositories  of : 

'S^.  Potass,  iod.,  1.00  (gr.  xv) ; 

lod.  puri.,  0.10  (gr.  jss); 

Extr.  laudan.,  0.15  (gr.  ij) ; 

Olei  theobr.  q.  s.  u.  f.  suppos.,  No.  x. 
or 

I^.  Potass,  iod.,  1.0-1.5  (gr.  xv-gr.  xxiv)  ; 

Solve  in  aq.  dest.,  adde 

mucilag.  semin.  cydon.,        150.0  (sivss). 
S. :  To  be  taken  as  a  clyster  after  1  stool. 

In  addition  lukewarm  sitz-baths.  The  bowels  must  be 
moved  daily.  Massage  of  the  prostate  also  has  a  good 
effect. 

Epididymitis. 

In  acute  epididymitis  compresses  of  ice-cold  water  or 
ice-bag.  The  bowels  must  l3e  regulated.  The  pain  is 
sometimes  so  great  that  the  exhibition  of  opiates  or  a  hy- 
podermatic injection  of  morphin  becomes  imperative. 


GONORRHEA.  113 

"Bf.  Bismuth,  subnitr.,  10.00  (sijss) ; 

Extr.  laudan.,  0.10  (gr.  jss). 

F.  pulv.  div.  in  dos.  sequal.,  No.  x. 
S. :  3  or  4  powders  daily. 

After  the  period  of  severe  pain  is  over,  inunctions  with 
the  following  preparations,  to  reduce  the  thickening  in 
epididymis  and  spermatic  cord  : 


^.  Extr.  bellad., 

1.00(gr.  xv); 

Ung.  ciner., 
Ung.  simpl., 
Ft.  ung. 

ad  10.00  (3ijss). 

or  painting  with 

R.  Tinct.  iod., 

Tinct.  gall., 

dd. 

or  with  : 

Ifj.  Iod.  puri.. 
Potass,  iod., 

0.02  (gr.i); 
2.50(gr.xl); 
25.00  (3\:jss). 

Ung.  emollient.. 

Ft.  ung. 

The  patient  should  also  be  directed  to  wear  a  well-fitt- 
ing suspensory.  Some  prefer  Fricke's  adhesive-plaster 
dressing. 


Chronic 

Cystitis, 

Irrigation  of  the 

bladder 

with  : 

^. 

Acid  boric. 
Aq.  dest.. 

) 

50.0  (ijss); 
1000.0  (Oij). 

^. 

Potass  hypermang., 
Aq.  dest., 

1.0-3.0 
1000.0 

(gr.  xv-xlv) ; 
(Oij). 

^. 

Formalin, 
Aq.  dest., 

8 

1.0  (gr.  xv); 
1000.0  (Oij). 

114  THE   VENEREAL  DISEASES. 

:^.  Argent,  nitr.,  1.00-2.50  (gr.  xv-xl); 

Aq.  dest.,       2000.00-1000.00  (Oiv  to  Oij). 

Balanitis  and  Balanoposthitis 

constitute  a  frequent  complication  of  urethral  gonorrhea 
in  the  male.  They  also  occur  without  urethral  disease. 
The  best  remedy  is  to  wash  the  penis  with  antiseptic 
lotions ;  if  there  is  phimosis,  the  preputial  sac  shoukt  be 
irrigated  with  a  1-3  per  cent,  solution  of  copper  sulphate 
or  with  a  solution  of  aluminum  acetate ;  in  addition  the 
part  should  be  dusted  with  : 

^.  Dermatoli, 

Amyli,  da. 

S.  :  Dusting-powder. 

I|i.  Acidi  salicyl., 

Zinci  oxydati,  1.0  (gr.  xv) ; 

Amyli,  da  10.0  (Sijss). 

Ft.  p. 
S. :  Dusting-powder. 

In  the  female,  gonorrhea  is  usually  localized  in  the 
vaginal  portions  of  the  urethra,  in  the  cervix,  and  in 
Bartholin's  glands.  The  urethral  affection  is  treated  ac- 
cording to  the  same  principles  as  in  the  male.  In  order 
to  remove  the  gonorrheal  secretion  which  flows  from  the 
cervix  and  collects  in  the  vagina,  it  is  well  to  irrigate  the 
part  with  a  lukewarm  2  per  cent,  solution  of  soda,  and 
after  that  with : 

^.  Cupr.  sulph.,  1.0  (gr.  xv) ; 

Aq.  dest.,  1000.0  (Oij). 

^.  Alumin.  crud.,  5.0  (3jss) ; 

Aq.  dest.,  1000.0  (Oij). 

!^.  Hydrarg.  chlor.  corr.,  1.0  (gr.  xv); 

Aq.  dest.,  1000.0  (Oij) 


GONORRHEA.  115 

^    Amnion,  siilphoichthyol.,    10.0-20.0  (3ijss-3v) ; 
Aq.  clest.,  1000.0  (Oij). 

To  combat  the  cervical  affection  1  per  cent,  solutions  of 
argentic  nitrate,  tincture  of  iodin,  and  iodoform  supposi- 
tories are  used.  Tiie  caustic  sulistances  are  applied  in 
solution  with  the  uterine  sound.  In  the  intervals  between 
the  applications  the  vagina  is  pacivcd  with  tampons  dipped 
in  the  above-named  substances,  the  tampons  being  fre- 
quently changed. 

Erosions  of  the  labia  are  to  be  s])rinkled  with  iodoform 
powder,  or  a  tampcm  of  iodoform  gauze  is  introduced  into 
the  vagina  as  far  as  the  orifice. 

In  suppuration  of  the  ducts  of  Bartholin's  glands  or  of 
the  glands  themselves  the  abscess  is  to  be  opened,  or  the 
entire  gland  is  extirpated.  In  catarrhal  inflammation  of 
the  duct  injections  of  about  1  per  cent,  argentic  nitrate 
solution  with  Anel's  syringe  are  to  be  recommended. 

Other  complications  of  gonorrhea  are  treated  according 
to  the  same  principles  as  in  the  male. 

Hematuria. 

The  patient  is  put  to  bed  and  the  bowels  are  regulated. 

^.  Extr.  hsemostatic,     2.0-3.0  (gr.  xxx-xlv) ; 
Aq.  dest.,  130.0  (f.?iv)  ; 

Syr.  acidi  hydriodic,      20.0  (3v). 
S.  :  One  tablespoonful  every  two  hours. 

Gonorrheal  Rheumatism. 

As  a  rule,  preparations  of  salicylic  acid  have  no  eflFect. 
This  peculiarity  of  the  gonorrheal  form  of  the  disease 
may  be  of  diagnostic  value  in  doubtful  cases.  We  re- 
commend potassium  iodid  in  doses  of  4  to  6  grs.  per 
diem  or 

I^.  Sodii  citrat.,  5.0  (gr.  x-3j)  ; 

D.  tal.  dos.  No.  x. 
S. :  4  powders  daily. 


116  THE  VENEREAL  DISEASES. 

To  allay  the  pain,  the  affected  joint  must  be  kept  abso- 
lutely quiet  and  treated  with  compresses  wet  with  alumi- 
num acetate  (liquor  Burow)  or  even  with  ice-bags.  If 
the  pain  is  very  intense,  especially  at  night,  hypodermatic 
injections  of  morphin  are  the  only  effective  remedy. 
After  the  inflammation  has  abated,  the  part  may  be 
dressed  with  a  starched  or  silica  bandage ;  the  patient 
feels  more  comfortable  and  is  better  able  to  change  his 
position.  If,  after  the  bandage  is  removed,  the  part  is 
still  swollen,  warm  baths,  massage,  and  painting  with 
tincture  of  iodin  are  to  be  recommended.  In  order  to 
prevent  a  more  or  less  permanent  stiffness,  the  patieht 
should  be  anesthetized  and  the  adhesions  severed  soon 
after  the  inflammatory  symptoms  have  subsided. 

Condylomata  Acuminata. 

Wash  with  antiseptic  lotions  (lysol  1  per  cent.,  carbol 
2  per  cent.,  copper  sulphate  1-3  per  cent.).  Compresses 
of  the  alkaline  earths  or  Burow's  solution  of  aluminum 
acetate  and  dusting-powders  : 

I|i.  Plumb,   acet.   basic,   crystallis. 
pulv.. 
Alum.  crud.  pulveris,  da  10.0  (sijss) ; 

Dermatol.,  30.0  h}) ; 

Talci  Venet.  subtil,  pulver.,      50.0  (3xiij). 

If  many  gonorrheal  warts  are  present,  they  should  be 
thoroughly  cleansed  and  moistened  with  water  and  then 
dusted  with 

^i.  Resorcin, 

Amyl.,  da  10.0  (sijss), 

after  which  they  are  to  be  isolated  with  gauze  until  the 
next  dressing,  which  should  take  place  after  five  or  six 
hours.  If  the  groups  are  large,  it  is  best  to  scrape  them 
out  thoroughly  with  a  curet,  and  cauterize  the  base  with 
chromic  acid  (25-50  per  cent.)  or  with  sesquichlorid  of 


GONORRHEA.  117 

iron.  Very  large  proliferations  must  be  excised  with 
their  base,  leaving  a  funnel-shaped  wound  which  is  sewed 
up  after  the  bleeding  has  stopped.  Removal  with  the 
thermocautery  is  often  the  simplest  and  most  radical 
operative  measure.  The  wound  is  afterward  treated  ac- 
cording to  the  recognized  principles  of  disinfection  and 
dressed  with  an  absorbent  bandage. 


INDEX. 


Abscess-pobmation,  10 
Adenitis,  Pis.  62,  63 

in  primary  stage,  9 

in  secondarj"^  stage,  12 

in  tertiary  stage,  38 

in  venereal  ulcers,  93,  97 

treatment  of,  74 
Albuminuria      during     mercurial 
treatment,  83 

in  tertiary  stage,  53 
Alopecia,  21 ;    Pis.   14,  14a,  20,   26, 

26a 
Amyloid  disease  of  kidney,  53 
Arteritis,  gummatous,  53 
Arthromeningitis,  36 
Astringents  in  acute  gonorrhea,  110 
Asymmetry  of  tertiary  lesions,  30 
Atrophy,  smooth,  of  base  of  tongue, 

42 
Autopsies,  Pis.  54,  54a,  58,  59 

Balanitis,  114 

Bartholin's  glands,  abscess   of,    PI. 
65 
in  gonorrhea,  115 
in  venereal  ulcer,  93 
Baths,  81,  83,  84 

Brain,  tertiary  lesions  of,  arteries, 
61 
base,  63 
cerebellum,  62 
cortex,  61 

general  pathology,  60 
meninges,  61 
Breast,  gumma  of,  57 ;  Pis.  48a,  48b 
Bronchi,  tertiary  lesions  of,  50 
Bubo,  treatment  of,  97 
in  venereal  ulcer,  93 
Bubonulus  Nisbethii,  10,  93 ;  PL  64 
Burow's  solution,  77,  116 

Caecinoma      distinguished     from 
gumma  42,45 


Care  of  mouth,  81,  83 
Caries  in  tertiary  stage,  33,  35 
Carriers  of  infection,  7 
Catarrh,  gastric,  in  tertiary  stage,  46 
Cause  of  tertiary  lesions,  29 
Cauterization  of  condylomata  acu- 
minata, 117 

of  initial  sclerosis,  73 

of  venereal  ulcers,  96 
Cavernitis,  PI.  66 
Cerebellum,  tertiary  lesions  of,  62 
Chancre,  soft.     See  Ulcer,  venereal. 
Channels  of  infection,  5 
Cheeks,  secondary  lesions,  26 

tertiary  lesions,  45 

treatment  of  papules  on,  75 
Cirrhosis,  syphilitic,  48 
Classification  of  stages,  2 
Colles'  law  of  immunity,  66 
Color-changes,  20 
Conditions  of  infection,  4 
Condylomata    acuminata,   24,   108; 
Pis.  67-69 
treatment  of,  116 
Cornea,  syphilitic,  59 
Course  of  syphilitic  disease  (scheme 

of),  4 
Cowper's  glands  in  gonorrhea,  103 
Cystitis,  gonorrheal,  106 
treatment  of.  111,  113 

Decoctum  Zittmanni,  88  ;  PI.  48a 
Degenerations  in  tertiarv  syphilis, 

31 
Diagnosis,  errors  in,  92,  95 
Ducrey-Krefting  bacillus  (venereal 

ulcer),  90 
Dusting-powders  for  venereal  ulcers, 

99 

Ear,  tertiary  svphilis  of,  45 
Ecthyma  pustule,  18 ;  Pis.  28,  29 
Eczema,  mercurial,  PI.  63 

119 


120 


INDEX. 


Edema,  indurative,  10,  24 ;  Pis.  5, 

12 
Endarteritis  obliterans,  53 
Endo-aortitis,  53 
Endocarditis,  51 

Epididymitis,  gonorrheal,  104,  112 
Epilepsy,  62 

Epiphyses,  disease  of,  69 
Errors  in  diagnosis,  92,  95 
Eruptions  during  pregnancy,  25 
Erythema  figuratum,  Pis.  15,  16 
Esophagus,  tertiary  syphilis  of,  45 
Excision  of  initial  sclerosis,  73 
Eye  (see  also  Hereditary  syphilis),  57 
disease  of  cornea,  59 

of  orbit,  58 
iritis,  condylomatous,  60 ;  PI.  43a 
plastic,  59 
serous,  59 
tarsitis,  59  ;  PI.  43b 
trachoma,  59 ;  PI.  43b 

Fauces,  secondary  lesions  of,  26 

treatment  of,  76 
Fissures,  PI.  31b 

treatment  of,  78 
Fourth  stage  of  syphilis,  28 
Frambesia,  21 ;  Pis.  29,  29a,  44,  45 
Fracture,    spontaneous,     in    osteo- 
myelitis, 36 

Gangeene  in  syphilitic  tissues,  9  ; 
Pis.  20,  54,  54a 

in  venereal  ulcer,  93 

treatment  of,  73 
Gastric  catarrh  in  tertiary  stage,  46 
Gingivitis,  PI.  20.  54,  54a" 
Gonococcus  of  Neisser,  101 

method  of  demonstration,  102 
Gonorrhea,  100  ;  PI.  66 

acute,  in  male,  101 
of  female,  105 

astringents  in,  110 

goutte  militaire,  103 

rectum  in,  107 

seminal  vesicles  in,  104 

symptoms  of,  101 

treatment  of,  109,  111 
Gonorrheal  rheumatism,  106,  115 

shreds,  103 
Gummata,  32;  Pis.  46-57 

cutaneous,  31 

distinguished    from    carcinoma, 
42,  45 


Gummata,  distinguished  from  ini- 
tial sclerosis,  56 
from  tubercular  nodes,  45 

fibrous,  35 
Gummatous  glossitis,  57 

hepatitis,  47 

myositis,  37 

osteomyelitis,  35 
Gums,  secondary  lesions  of,  27 

tertiary  lesions  of,  45 

Headache,  treatment  of,  80 
Heart,  endocarditis  and  pericardi- 
tis, 51 
myocarditis,  fibrous,  51 
Hematuria,  treatment  of,  115 
Hemorrhages,  cutaneous,  19  ;  PI.  70 
Hemorrhagica  syphilitica  neonato- 
rum, 67 
Hepar  lobatum,  48 
Hepatitis,  gummatous,  47 

interstitial,  47 
Hereditary  syphilis,  64 ;  Pis.  58,  59, 
60  a-c 
eye  symptoms.  Pi.  6a  a-c 
immunity,  66 
infection,  64-66 
mortality  in — table,  67 
pemphigus,  67 
prognosis  of,  66 

syphilis  hereditaria  prsecox,  67 
tarda,  69 
symptoms  of,  71 
treatment  of,  70 
Hutchinson's  symptoms,  70 ;  PI.  60 

a-c 
Hydrocele,  acute,  105 
Hypodermatic  methods,  85 

Immunity,  66 

Infantile  acquired  syphilis,  70 

Infection,  channels  of,  5 

germinal,  64 

mode  and  conditions,  1-5 

ovular,  65 

spermatic,  65 
Infective      power      of      syphilitic 
lesions,  6,  25 
of  venereal  ulcers,  8,  90 
Initial  forms,  treatment  of,  72 

sclerosis,  8 ;  Pis.  1-11 

seats,  9,  73 
Injections  in  acute  gonorrhea,  109 

hypodermatic,  85 


INDEX. 


121 


Insomnia,  11 

treatment  of,  80 
Intermission  period,  29 
Intestines  in  tertiary  stage,  46 
Inunctions,  mercurial,  82 
lodids,  use  of,  86 
Iritis,  condylomatous,  60;  PI.  43a 

plastic,  59 

serous,  59 
Irritative  stage,  3 

Jaundice,  PI.  18 

Keratitis,  interstitial,  59 
Kidney,  amyloid  disease  of,  53 
in  tertiary  stage,  53 

Labareaque's  solution,  77 
Larynx,  tertiary  syphilis  of,  50 

treatment  of,  76 
Latent  stage,  29 
Leontiasis  syphilitica,  34 
Leukoplasia,  15,  20,  42 ;  Pis.  20,  24, 

24a,  36,  38,  41b,  42b,  53 
Lichenoid  papules,  15;  PI.  19 
Lips,  secondary  lesions,  26 

tertiary  lesions,  45 

treatment  of  papules  on,  75 
Liver,  tertiary  syphilis  of,  47 
Lotions  for  venereal  ulcers,  99 
Lungs,  tertiary  syphilis  of,  51 
Lupus,  syphilitic,  34 
Lymphangitis,  9 ;  PI.  64 

Macular  syphilide,  13;  PI.  14 

roseola,  14 ;  PI.  13 
Malignant  forms  of  syphilis,  4 
Mercurial  stomatitis,  82 
Mercury,  hvpodermatic  injections, 
85  ' 

internal  use  of,  86 

inunctions,  82 
Molluscum  contagiosum,  PI.  71 
Mouth,  care  of,  81,  83 
Myelomalacia,  63 
Myelomeningitis,  C3 
Myocarditis,  fibrous,  51 
Myositis  in  tertiary  stage,  33,  37 

Nasal  cavity,  tertiary  syphilis  of, 

50 
Navel,  disease  of,  68 
Necrosis,  PI.  41a,  64 
Neuritis,  64 


Onychia,  23  ;  PI.  32 

treatment  of,  78 
Orbicular  syphilide,  16;  PI.  16 
Orchitis,  fibrous,  54 

gummatous,  55 
Osteomyelitis,  35 

spontaneous  fracture  in,  36 

Pachydermia  syphilitica,  41 
Palate,  secondary  lesions,  26 

tertiary  lesions,  43 
Pancreas,  tertiary  lesions,  48 
Papillomata,  venereal,  25 
Papulae  luxuriantes,  25 
Papular  svphilide,  15 ;  Pis.  14,  14a, 
17,  19-26,  31-42,  58,  59 
irregular  forms,  16  ;  PI.  22,  23 
lenticular  papules,  15 
lichenoid  papules,  15  ;  PI.  19 
papulae  nitentes,  16;   PI.  25 
orbicular  papules,  16  ;  PI.  21 
treatment  of,  77,  84 
Paraphimosis,  10;  PI.  63 

treatment  of,  74 
Paronychia.  23 ;  PI.  32 

treatment  of,  78 
Pemphigus,  6,  67 
Pericarditis,  51 
Periostitis,  spontaneous,  35 
Pharynx,  44 
Phimosis,  10  ;  PI.  63 

treatment  of,  73 
Pigmentation,  20 
Plenck's  solution,  77 
Pregnancy,  eruptions  in,  25 
Primary  lesion  (see  Initial  sclerosis), 

8 
Prognosis  in  general,  3 
in  hereditary  syphilis,  66 
in  synovitis,  37 
Prostate  gland  in  gonorrhea,  104 
Prostatitis,  treatment  of,  112 
Psoriasis,  22;    Pis.  12,  13,  14,  14a, 
26a,  30 
mucosa  oris,  42 ;  Pis.  41b,  42b 
treatment  of,  78 
Pustular  syphilide,  17 ;   Pis.  17,  27, 
28,  28a,  28b,  58,  59 
ecthyma  pustule,  18;  Pis.  28,  29 
major,  18 

minor  or  acneiform,  18 
variola  syphilitica,  17 
vesicular  syphilide,  17 
Pyelitis,  gonorrheal,  106 


122 


INDEX. 


Rectum  in  gonorrhea,  107 
Rheumatism,  gonorrheal,  106 

treatment  of,  115 
Roseola,  14;  Pis.  5,  11,  13 
Eupia,  syphilitic,  18,  33 ;  Pis.  44,  45, 
49 

Saddle-nose   in  hereditary  syph- 
ilis, PI.  60  a-c 
Scalp,  diseases  of,  21 ;   Pis.  14,  14a, 
20,  26,  26a 
treatment  of,  29 
Scar-formation  in  syphilides,  32 
Seborrhcea  capitis,  21 
Seminal  vesicles  in  gonorrhea,  104 
Spina  ventosa,  36 

Spinal  cord,  tertiary  syphilis  of,  46 
Spleen,  tertiary  syphilis  of,  40 
Stomach,    catarrh    of,   in    tertiary 

syphilis,  46 
Stomatitis,  mercurial,  82 
Suprarenal   body  in  tertiary  syph- 
ilis, 41  ' 
Syphilides,  general  character,  (see 
Macular,  Papular,  Pustular, 
Gumnata),  13 
scar-formation  in,  32 
Syphilis,  classification  of  stages  of,  2 
first  phenomena,  7 
"fourth,"  28 
prsecox,  67 ;  Pis.  44,  45 
primary,  4 
adenitis,  10 

phimosis  and  paraphimosis,  10 
secondary,  11 
adenitis,  12 
exanthemata,  13-18 
insomnia,  11 
prodromal  symptoms,  11 
tertiary, 
asymmetry  of  lesions,  30 
cause  of  tertiary  lesions,  29 
degenerations  in,  31 
general  character  of  lesions,  30 
infective  power  in,  6,  7,  25 
manner  of  occurrence,  30 
serpiginous  ulcers,  31,  33;   PI. 
51 
Syphiloma,  diflTuse  hypertrophic,  34 

Tabes,  64 

Tarsitis,  59  ;  PI.  43b 
Tendons,    disease    of,    in    tertiary 
syphilis,  38 


Tenosynovitis  in  gonorrheal  rheu- 
matism, 106 
Testicles  in  tertiary  syphilis,  54 
Thymus  gland  in  hereditary  syph- 
ilis, 68 
Thyroid  gland  in  tertiary  stage,  40 
Tongue,  secondary  lesions  of,  27 
tertiary  lesions  of,  41,  43 
treatment  of,  76 
Tonics,  81,  83 

Tonsils,    leukoplasia    of,   Pis.   41b, 
42b,  43 
secondary  lesions  of,  26 
Tophi,  35 

Trachea  in  tertiary  svphilis,  50 
Trachoma,  59;  PI.  43b 
Transmission   in  hereditary  syph- 
ilis, 66 
of  virus  in  initial  forms,  72 
Treatment,  72 
antiseptic,  73 
chronic  intermittent,  80 
expectant,  79 
fissures  about  the  anus,  78 
general,  79,  83 

gonorrhea  and  complications,  109- 
111 
.  local,  of  secondary  and  tertiary 
forms,  75 
mercurial,  82 
venereal  ulcers,  96 
Tubercular     nodes     distinguished 
from  gummata,  45 

Ulcers,  venereal,  89 ;  Pis.  61,  62, 
63 

cauterization  of,  96 

character  of  sore,  90 

complications,  93 

course,  91 

dusting-powders  for,  99 

errors  in  diagnosis,  92,  95 

induration  simulated,  90 

infective  power,  8,  90 

lotions,  99 

seats,  91,  92,  93 

treatment  of,  96 
Uterus,  tertiary  syphilis  of,  57 

Variola  syphilitica,  17 
Veins  in  tertiary  stage,  53 
Vienna  paste,  96 
Virus,  transmission  of,  72 
where  found,  6,  7 


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ABBOTT  ON  TRANSMISSIBLE  DISEASES.    Second  Edition, 
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CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.  By  JOHN  B.  Chapin,  M.  D.,  LL.D.,  Phy- 
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CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 

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CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DIS- 
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CORWIN'S  PHYSICAL  DIAGNOSIS.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  ARTHUR  M.  CORWIN, 
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CROTHERS'  MORPHINISM  AND  NARCOMANIA. 

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DACOSTA'S  SURGERY.    Third  Edition,  Revised. 

Modern  Surgery,  General  and  Operative.  By  JoHN  CHALMERS  DaCosta, 
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DAVIS'S  OBSTETRIC  NURSING. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M.,  M.  D., 
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Polyclinic ;  Obstetrician  and  Gynecologist  to  the  Philadelphia  Hospital. 
i2mo  volume  of  400  pages,  fully  illustrated.     Crushed  buckram,  ^1.75  net. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.     Fourth  Edi- 
tion, Entirely  Reset ;  Thoroughly  Revised  and  Enlarged. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G.  E. 
DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical 
College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  700  pages ; 
300  fine  illustrations  and  6  full-page  chromo-lithographic  plates.  Cloth, 
$5.00  net ;  Sheep  or  Half  Morocco,  $(i.oo  net. 

DORLAND'S  DICTIONARIES. 

[See  Atnericau  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

DORLAND'S    OBSTETRICS.      Second    Edition,    Revised    and 
Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Associate  in  Gyne- 
cology, Philadelphia  Polyclinic.  Octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  $i,.oo  net. 

EICHHORST'S  PRACTICE  OF  MEDICINE. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  HERMANN  ElCH- 
HORST,  Professor  of  Special  Pathology  and  Therapeutics  and  Director  of 
the  Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by  Al'GUS- 
TLS  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Poly- 
clinic. Two  royal  octavo  volumes,  600  pages  each,  150  illustrations.  Per 
set :  Cloth,  $6.00  net ;  Sheep  or  Half  Morocco,  ^7.50  net. 

EYRE'S  BACTERIOLOQIC  TECHNIQUE. 

Bacteriologic  Technique.  A  Laboratory  Guide  for  the  Medical,  Dental, 
and  Technical  Student.  By  J.  W.  H.  Eyrk,  M.  D.,  F.  R.  S.  Edin.,  Lec- 
turer on  Bacteriology  and  Joint  Lecturer  on  Practical  Public  Health, 
Charing  Cross  Hospital  Medical  School ;  Bacteriologist  to  Charing  Cross 
and  to  St.  Mary's  Hospital  for  Sick  Children,  Plaistow.  Handsome  octavo 
of  350  pages,  with  150  illustrations.     Cloth,  ;jo.oo  net. 


OF  IK  B.   SAUNDERS  &-  CO. 


FRIEDRICH   AND  CURTIS    ON    THE   NOSE,  THROAT,   AND 
EAR. 

Rhinology,  Laryngology,  and  Otology,  and  their  Significance  in  General 
Medicine'.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H.  HOLBROOK 
Curtis,  AL  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat  Hos- 
pital.    Octavo,  348  pages.     Cloth,  $2.50  net. 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  LaNGDON  FrothingHAM, 
^L  D.  v.,  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield  Scien- 
tific School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

QALBRAITH  ON  THE  FOUR  EPOCHS  OF  WOMAN'S  LIFE. 

The  F'our  Epochs  of  Woman's  Life.  A  Study  in  Hygiene.  By  ANNA  M. 
Galbraith,  M.  D.,  Author  of  "  Hygiene  and  Physical' Culture  for  Women"; 
Fellow  of  tlie  New  York  Academy  of  Medicine,  etc.  With  an  Introductory 
Note  by  JoHN  H.  MusSER,  M.  D.,  Professor  of  Clinical  Medicine,  University 
of  Pennsylvania.     i2mo  volume  of  200  pages.     Cloth,  $1.25  net. 

OARRIQUES'  DISEASES  OF  WOMEN.    Third  Ed.,  Revised. 

Diseases  of  Women.  By  Henry  j.  Garrigues,  A.  M.,  M.  D.,  Gynecolo- 
gist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  York  City. 
Octavo,  756  pages,  with  367  engravings  and  colored  plates.  Cloth,  $.\.SO 
net ;  Sheep  or  Half  Morocco,  $5.50  net. 

GORHAM'S  BACTERIOLOGY. 

.\  Laboratory  Course  in  Bacteriology.  By  F.  P.  GORHAM,  M.  A.,  Assistant 
Professor  in  Biology,  Brown  University.  i2mo  volume  of  192  pages,  97 
illustrations.     Cloth,  $1.25  net. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

.Anomalies  and  Curiosities  of  Medicine.  By  (jEORGE  M.  GoULD,  M.  D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and  ex- 
traordinai-y  cases  and  of  the  most  striking  instances  of  abnormality  in  all 
branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present  day,  abstracted,  classified, 
annotated,  and  indexed.  Handsome  octavo  volume  of  968  pages ;  295  en- 
gravings and  12  full-page  plates.  Popular  EdiUon.  Cloth,  $3.00  net ;  Sheep 
or  Half  Morocco,  $4.00  net.  ~ ' 

GRADLE  ON  THE  NOSE,  THROAT,  AND  EAR. 

Diseases  of  the  .\ose.  Throat,  and  Ear.  By  Henry  Gradle,  M.D.,  Pro- 
fessor of  Ophthalmology  and  Otology,  Northwestern  University  Medical 
School.  Chicago.  Octavo,  547  pages,  illustrated,  including  2  full-page 
colored  plates.     Cloth,  ;5S3.5o  net. 


MEDICAL  PUBLICA  TIONS 


GRAFSTROM'S  MECHANO-THERAPY. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc.  M.D.,  late  House  Physician'  City  Hos- 
pital, Blackwell's  Island,  N.Y.   i2mo,  139  pages,  illustrated.  Cloth, $1.00  net. 

GRANT'S   SURGICAL    DISEASES  OF    THE    FACE,   MOUTH, 
AND  JAWS.     For  Dental  Students. 

A  Text-Book  of  Surgical  Pathology  and  Surgical  Diseases  of  the  Face, 
Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace  Grant,  A.  M., 
M.D.,  Professor  of  Surgical  Pathology  and  Oral  Surgery,  Louisville  Col- 
lege of  Dentistry  ;  Professor  of  Surgery  and  Clinical  Surgery,  Hospital 
College  of  Medicine,  Louisville,  Ky.  Octavo  volume  of  215  pages,  with 
60  illustrations.     Cloth,  $0.00  net. 

GRIFFITH  ON  THE  BABY.    Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical  Pro- 
fessor of  Diseases  of  Children,  University  of  Pennsylvania  ;  Physician  to  the 
Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages,  67  illustrations 
and  5  plates.     Cloth,  $1.^0  net. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania.  25 
charts  in  each  pad.     Per  pad,  50  cts.  net. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of  Prac- 
tical Anatomy  in  Cornell  University  Medical  College.  680  pages ;  42  dia- 
grams and  134  full-page  half-tone  illustrations  from  original  photographs  of 
the  author's  dissections.     Cloth,  $2.50  net. 

HEISLER'S  EMBRYOLOGY.     Second  Edition,  Revised. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor  of 
Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume  of  405 
pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

HIRST'S  OBSTETRICS.    Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume  of 
873  pages,  704  illustrations,  36  of  them  in  colors.  Cloth,  ;Js.oo  net ;  Sheep 
or  Half  Morocco,  $6.00  net. 

HYDE  &  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.    2d  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D.,  Pro- 
fessor of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  Frank  H. 
Montgomery,  M.  D.,  .'Associate  Professor  of  Skin,  Genito-Urinary,  and 
Venereal  Diseases  in  Rush  Medical  College,  Chicago,  III.  Octavo,  594 
pages,  profusely  illustrated.     Cloth,  $4.00  net. 


OF  W.  B.   SAUNDERS  <Sr^  CO. 


INTERNATIONAL  TEXT=BOOK  OF  SURGERY.    Two  Volumes. 
2d  Ed.,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren,  M.  D., 
LL.  D.,  F.  R.C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School, 
Boston  ;  and  A.  Pearce  Gould,  M.S.,  F.  R.  C.  S.,  Lecturer  on  Practical 
Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  L  General  Surgery. — Handsome  octavo,  947 
pages,  with  458  beautiful  illustrations  and  9  lithographic  plates.  Vol.  IL 
Special  or  Regional  Surgery. — Handsome  octavo,  1072  pages,  with  471 
beautiful  illustrations  and  8  lithographic  plates.  Prices  per  volume : 
Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  ;g6.oo  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The 
clinician  and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a 
satisfaction  to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  of 
Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has 
ver>'  many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different 
authors  is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor 
of  each  writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the 
technique  of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up 
to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional 
parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which 
the  reader  may  not  learn  something  new." — Medical  Record,  New  York. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and  Col- 
lege for  Graduates  in  Medicine.  i2mo,  volume  of  535  pages,  with  178  illus- 
trations, mostly  from  drawings  by  the  author.     Cloth,  IS2.50  net. 

JELLIFFE  AND  DIEKMAN'S  CHEMISTRY. 

.\  Text-Book  of  Chemistry.  By  SMITH  ELY  Jelliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York  ;  and  George 
C.  DiEKMAN,  Ph.  G.,  M.  D.,  Professor  of  Theoretical  and  Applied  Phar- 
macy, College  of  Pharmacy,  New  York.  Octavo,  550  pages,  illustrated. 
Ready  Shortly. 

KEATING'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  JOHN  M.  Keating,  M.  D.,  Fellow 
of  the  College  of  Physicians  of  Philadelphia  ;  Ex- President  of  the  Association 
of  Life  Insurance  Medical  Directors.  Royal  octavo,  211  pages.  With 
numerous  illustrations.     Cloth,  $2.00  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm.  W. 
Keen,  M.  D.,  LL.D.,  F,  R.  C.  S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.     Cloth,  $3.00  net. 

KEEN'S  OPERATION  BLANK.    Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required  in  Various 
Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.D.,  F.  R.  C.S.  (Hon.), 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.     Price  per  pad,  of  50  blanks,  50  cts.  net.* 

KYLE  ON  THE  NOSE  AND  THROAT.    Second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  646  pages  ;  over  150  illustrations  and  6  lithographic  plates. 
Cloth,  ;^.oo  net ;  Sheep  or  Half  Morocco,  ;J55.oo  net. 


MEDICAL  PUBLICATIONS 


lain6's  temperature  chart. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8  x  135^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature,  with 
columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Re- 
marks, etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment  of 
Typlioid  Fever.     Price,  per  pad  of  25  cliarts,  50  cts.  net. 

LEVY,  KLEMPERER,  AND  ESHNER'S  CLINICAL  BACTERI- 
OLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Professor 
in  the  University  of  Strasburg,  and  Dr.  Felix  Klemperer,  Privatdocent 
in  the  University  of  Strasburg.  Translated  and  edited  by  AUGUSTUS  A. 
EsHNER,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic. 
Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S    PRACTICE    OF    MEDICINE.    Second  Edition, 
Revised  and  Enlarged. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lockwood, 
M.D.,  Attending  Physician  t>  Bellevue  Hospital,  New  York.  Octavo,  847 
pages,  fully  illustrated,  including  22  colored  plates.     Cloth,  $4.00  nek 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  LoNG,  M.D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macuo.NALD,  M.  D.  Edin., 
F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery, 
Hamline  University.  Handsome  octavo,  800  pages,  fully  illustrated.  Cloth, 
$5.00  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 
Second  Edition,  Revised  and  Enlarged. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  FRANK  B. 
Mallory,  a.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard  Uni- 
versity Medical  School,  Boston;  and  James  H.  Wright.  A.M.,  M.D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston. 
Octavo,  432  pages,  fully  illustrated.     Cloth,  $3.00  net. 

McCLELLAN'S  ANATOMY  IN  ITS  RELATION  TO  ART. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and  Muscles 
of  the  Human  Body,  with  Reference  to  their  Influence  upon  its  .Actions 
and  External  Form.  By  George  McClellan,  M.  D.,  Professor  of  Anat- 
omy, Pennsylvania  Academy  of  Fine  Arts.  Handsome  quarto,  9  by  11^ 
inches.  Illustrated  with  338  original  drawings  and  photographs,  260  pages 
of  text.     Dark  Blue  Vellum,  $10.00  net ;   Half  Russia,  $12.00  net. 

McCLELLAN'S  REGIONAL  ANATOMY.     Fourth  Edition,  Re= 
vised. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  Bv  George 
McClellan,  M.  D.,  Professor  of  Anatomy  at  the  Pennsylvania  Academy 
of  Fine  .Arts.  In  two  handsome  quarto  volumes,  884  pages  of  text,  and 
97  full-page  chromo-lithographic  i)lates,  reproducing  the  author's  original 
dissections.     Price:  Cloth,  ;$i2. 00  net ;   Half  Russia,  $15.00  net. 


OF  W.  B.   SAUNDERS  &-  CO.  ii 


McFARLAND'S    PATHOGENIC    BACTERIA.      Third    Edition, 

increased  in  size  by  over  lOO  Pages. 

Text-Book  upon  the  Pathogenic  Bacteria.  By  JOSEPH  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical  Col- 
lege, Phila.,  etc.     Octavo,  621  pages,  finely  illustrated.     Cloth,  $3.25  net. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  ARTHUR  V.  MEIGS,  M.  D.  Bound  in  limp 
cloth,  flush  edges,  25  cts.  net. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  lAME$  E.  MOORE,  M.  D.,  Professor 
of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of 
Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume  of  356  pages, 
handsomely  illustrated.     Cloth,  32.50  net. 

MORTEN'S  NURSES'  DICTIONARY. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Containing 
Definitions  of  the  Principal  Medical  and  Nursing  Terms  and  Abbreviations  ; 
of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations, 
Foods,  Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  By 
HoNNOR  IVlORTEN,  author  of  "  Howr  to  Become  a  Nurse,"  etc.  i6mo,  140 
pages.     Cloth,  ;gi.oo  net. 

NANCREDE'S  ANATOMY  AND  DISSECTION.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  CHARLES 
B.  NaNCREDE,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with  full-page 
lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra  Cloth  (or 
Oilcloth  for  dissection-room),  ;{52. 00  net. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  Charles  B.  Nancrede,  M.  D., 
LL.D,,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.     Cloth,  |52. 50  net. 

NORRIS'S    SYLLABUS    OF    OBSTETRICS.     Third    Edition, 
Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department,  University  of 
Pennsylvania.  By  Richard  C.  Norris,  A.  M.,  M.  D.,  Instructor  in  Obstet- 
rics and  Lecturer  on  Clinical  and  Operative  Obstetrics.  University  of  Penn- 
sylvania.    Crown  octavo,  222  pages.     Cloth,  interleaved,  ;$2.oo  net. 

OGDEN  ON  THE  URINE. 

Clinical  Examination  of  the  Urine  and  Urinan'  Diagnosis.  A  Clinical  Guide 
for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Surgery.  By  J. 
Bergen  Ogden,  M.  D.,  l.-itely  Instructor  in  Chemistry,  Harvard  Univer- 
sity Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  ^3.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  CiLVRLES  B.  Pknro.se,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  539  pages,  with  221  illustrations.     Cloth,  $3.75  net. 


MEDICAL  PUBLICATIONS 


PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  concerning 
the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter  Pye, 
F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic  Basis. 
Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the  Wills  Eye 
Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully  illustrated. 
Cloth,  ^1.50  net. 

RAYMOND'S    PHYSIOLOGY.      Second  Edition,   Entirely    Re- 
written and  Greatly  Enlarged. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College  Hospital, 
and  Director  of  Physiology  in  Hoagland  Laboratory,  New  York.  Octavo, 
668  pages,  443  illustrations.     Cloth,  ^3.50  net. 

ROBSON  AND  MOYNIHAN'S  DISEASES  OF  THE  PANCREAS. 

Diseases  of  the  Pancreas.  By  A.  W.  Mayo  Robson,  F.  R.  C.  S.,  Leeds, 
Senior  Surgeon  to  Leeds  General  Infirmary  ;  Emeritus  Professor  of  Surgery, 
Yorkshire  College  of  Victoria  University  ;  and  B.  G.  A.  Moynihan,  M.  B., 
F.  R.  C.  S.,  Assistant  Surgeon  Leeds  General  Infirmary  ;  Demonstrator  of 
Anatomy,  Yorkshire  College.  Handsome  octavo  of  300  pages,  illustrated. 
Cloth,     ^0.00  net. 

SALINGER  AND  KALTEYER'S  MODERN  MEDICINE. 

Modern  Medicine.  By  JULIUS  L.  Salinger,  M.  D.,  Professor  of  Clin- 
ical Medicine,  Jefferson  Medical  College;  and  F.  J.  Kalteyer,  M.  D., 
Assistant  in  Clinical  Medicine,  Jefferson  Medical  College.  Handsom© 
octavo,  801  pages,  illustrated.     Cloth,  ;^4.oo  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundbv,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Royal 
Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason  College,  Bir- 
mingham, etc.  Octavo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.     Cloth,  $2.50  net. 

SAUNDERS'  MEDICAL  HAND-ATLASES.     See  pages   17,  18, 
and  19. 

SAUNDERS'  POCKET   MEDICAL  FORMULARY.     Sixth  Edi- 
tion, Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "  Essentials  of  Diseases  of 
Children  "  ;  Member  of  Philadelphia  Pathological  Society.  Containing  1844 
formulae  from  the  best-known  authorities.  With  an  Appendix  containing 
Posological  Table,  Formulae  and  Doses  for  Hypodermic  Medication, 
Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal 
Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs  used  in  Antiseptic 
Surgery,  Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer, 
Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  Flexible  morocco, 
with  side  index,  wallet,  and  flap.    $2.00  net. 


OF  W.  B.  SAUNDERS  &■■  CO.  13 


SAUNDERS'  QUESTION=COMPENDS.     See  page  16. 

SCUDDER'S  FRACTURES.    Third  Edition,  Revised. 

The  Treatment  of  Fractures.     By  Chas  L.  Scudder,  M.  D.,  Assistant  in 
Clinical  and  Operative  Surgery,  Harvard  University  Medical  School.     Oc- 
tavo, 433  pages,  with  nearly  600  original  illustrations.     Polished  Buckram, 
net ;  Half  Morocco,  net. 

SENN'S  QENITO-URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By  Nich- 
olas Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  320  pages,  illustrated. 
Cloth,  $3.00  net. 

SENN'S  PRACTICAL  SURGERY. 

Practical  Surgery.  By  NICHOLAS  Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor 
of  Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo  volume 
of  1133  pages,  642  illustrations.  Cloth,  ^6.00  net;  Sheep  or  Half  Morocco, 
^7.00  net.     By  Subscription. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  conformity 
with  "An  American  Te.\t-Book  of  Surgery."  By  NICHOLAS  Senn,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Cloth,  $1.50  net. 

SENN'S  TUMORS.    Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  NICHOLAS  SENN,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages,  with  478  illustrations,  includ- 
ing 12  full-page  plates  in  colors.  Cloth,  ;$5.oo  net ;  Sheep  or  Half 
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SOLLMANN'S  PHARMACOLOGY. 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D.,  Assistant 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Univer- 
sity, Cleveland,  Ohio.  Royal  octavo  volume  of  894  pages,  fully  illustrated. 
Cloth,  $3.75  net. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis  STARR, 
M.  D.,  Editor  of  "  An  American  Text-Book  of  the  Diseases  of  Children." 
230  blanks  (pocket-book  size),  perforated  and  neatly  bound  in  flexible 
morocco.     ;?i.25  net. 

STELWAQON'S  DISEASES  OF  THE  SKIN. 

Diseases  of  the  Skin.  By  He.nry  W.  Stelwagon,  M.  D.,  Qinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo  of  1075  pages,  with  220  text-cuts  and  26  half-tone  and  colored  plates. 
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14  AJEDfCAL  PUBLICATIONS 


STENGEL'S  PATHOLOGY.  Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel.  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania ;  Visiting  Physician  to  the 
Pennsylvania  Hospital.  Octavo,  873  pages,  nearly  400  illustrations  many 
of  them  in  colors.     Cloth,  ;^5.oo  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

STENGEL  AND  WHITE  ON  THE  BLOOD. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  ALFRED  STEN- 
GEL. M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania  ;  and 
C.  Y.  White,  Jr.,  M.D.,  Instructor  in  Clinical  Medicine,  University  of 
Pennsylvania.     In  Press. 

STEVENS'  MATERIA  MEDICA  AND  THERAPEUTICS.     Third 
Edition,  Entirely  Rewritten  and  Greatly  Enlarged. 

A  Te.xt-Book  of  Modern  Therapeutics.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania.  Hand- 
some octavo  volume  of  about  550  pages.     Cloth,  ^0.00  net. 

STEVENS'  PRACTICE  OF  MEDICINE.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  STEVENS,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania.  Spe- 
cially intended  for  students  preparing  for  graduation  and  hospital  examina- 
tions.    Post-octavo,  519  pages  ;  illustrated.     Flexible  Leather,  ;jS2.oo  net. 

STEWART'S  PHYSIOLOGY.     Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and  Prac- 
titioners. By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of  Physiol- 
ogy and  Histology,  Western  Reserve  University,  Cleveland,  Ohio.  Octavo, 
894  pages;  336  illustrations  and  5  colored  plates.     Cloth,  §3.75  net. 

STONEY'S  MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  the  late  EMILY  A.  M.  Stoney,  Superin- 
tendent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Bos- 
ton, Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  $1.50  net. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  the  late 
Emily  .A.  M.  Stoney,  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings  and 
8  colored  and  half-tone  plates.     Cloth,  $i.7S  ^'^^■ 

STONEY'S  SURGICAL  TECHNIC  FOR  NURSES. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  the  late  EMILY  A.  M. 
Stoney,  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hos- 
pital, South  IBoston,  Mass.    lamo  volume,  fully  illustrated.    Cloth,  $1.25  net. 

THOMAS'S  DIET  LISTS.     Second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D,,  In- 
structor in  Materia  Medica,  Long  Island  Hospital ;  Assistant  Bacteriologist 
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OF  ir.   B.  SAUXDERS  ^  CO.  15 


THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITINO. 
Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  THORNTON, 
M.  D.,  demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Philadel- 
phia.    Post-octavo,  362  pages,  illustrated.     Flexible  Leather,  ^2.00  net. 

VECKI'S  SEXUAL  IMPOTENCE.    Third  Edition,  Revised. 

The  Pathology  and  Treatnu-nt  jf  Se.xual  Impotence.  By  Victor  G.  Vecki, 
M.  D.  From  the  second  German  edition,  revised  and  enlarged.  Demi- 
octavo,  329  pages.     Cloth,  32.00  net. 

VIERORDT'S    MEDICAL    DIAGNOSIS.      Fourth    Edition,  Re= 
vised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth  en- 
larged German  edition,  with  the  author's  permission,  by  FRANCIS  H. 
Stuart,  .A.  M.,  M.D.  Handsome  octavo  volume,  603  pages;  194  wood- 
cuts, many  of  them  in  colors.  Cloth,  4.00  net;  Sheep  or  Half-Morocco, 
1(5.00  net. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  [.  K.  WaTSON,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A!  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on 
Physical  Diagnosis,  University  of  Pennsylvania.  lamo,  413  pages,  73  illus- 
trations.    Cloth,  %\.yi  net. 

WARREN'S  SURGICAL  PATHOLOGY.    Second  Edition. 

Surgical  Pathology  and  Therapeudcs.  By  JoHN  COLLINS  Warren,  M.  D., 
LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School. 
Handsome  octavo,  873  pages  ;  136  relief  and  lithographic  illustrations,  33  in 
colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and  a 
series  of  articles  on  Regional  Bacteriology.  Cloth  ^5.00  net ;  Sheep  or 
Half  Morocco,  $6.00  net. 

WARWICK  AND  TUNSTALL'S  FIRST  AID  TO  THE  INJURED 
AND  SICK. 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.  A.,  M.  B. 
Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  .\.  C.  TlNSTALL,  M.  D.,  F.  R.  C.  S.  Ed.,  Sur- 
geon-Captain commanding  East  Londoa  Volunteer  Brigade  Bearer  Com- 
pany.    i6iuo,  232  pages,  and  nearly  200  illustrations.     Cloth,  $1.00  net. 

WOLF'S  EXAMINATION  OF  URINE. 

A  Hand-Book  of  Physiologic  Chemistry  and  Urine  E.vamination.  By 
Charles  G.  L.  Wolf.  M.D.,  Instructor  in  Physiologic  Chemistry,  Cor- 
nell University  Medical  College.  i2mo  volume  of  204  pages,  47  illustra- 
tions.    Cloth,  $1.25  net. 


Saunders' 
Question=Compend   Series. 

Price,  Cloth,  $i.oo  net  per  copy,  except  when  otherwise  noted. 


'  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders 
Series,  in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials   of   Physiology.      By   Sidney   Budgett,   M.  D.    An  entirely  new 

work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised, 

with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth   edition, 

thoroughly  revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.   By  Lawrence 

Wolff,  M.  D.     Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.        Fifth    edition, 

revised  and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.    By  F.  J.  Kalteyer,  M.  D. 

In  preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- Writing. 

By  Henrv  Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.     Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Ap- 

pendix on  Urine  Examin.ation.  By  Lawrence  Wolff,  M.  D.  Third  edition, 
enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by 
Wm.  M.  Powell,  M.  D.     (Double  number,  $i.$o  net.) 

10.  Essentials   of   GynecOlOgfy.     By   Edwin  B.   Cragin,  M.  D.        Fifth    edition, 

revised. 

11.  Essentials  of  Diseases  of  the  Skin.    By  Henry  w.  Stelwagon,  m.  D. 

Fourth  edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials  of  Legal  Medicine,  Toxicology,  and  Hygiene.    This  volume  is 

at  present  out  of  print. 

14.  Essentials   of  Diseases   of  the  Eye.     By   Edward  Jackson,   M.  D.     Third 

edition,  revised  and  enlarged. 
IB.     Essentials  Of  Diseases  Of  Children.     By  William  M.  Powell,  M.  D.    Third 

16.  Essentials  of  Examination  Of  Urine.     By  Lawrence  Wolff,  M.  D.     Colored 

"  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.  Solis-Cohen,  ^L  D.,  and  A.  A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials  of  Practice  of  Pharmacy.     By  Lucius  E.  Sayrb.    Second  edition, 

revised  and  enlarged. 

19.'    Essentials  of  Diseases  of  the  Nose  and  Throat.    By  E.  B.  Glbason,  m.  D 

Third  edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  v.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.    By  John  C.  Shaw,  m.  D. 

Third  edition,  revised. 

22.  Essentials  of  Medical  Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edi- 

tion, revised. 

23.  Essentials  of  Medical  Electricity.    By  David  D.  Stewart,  M.  D.,  and  Ed- 

ward S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.    By  E.  B.  Gleason,  M.  D.    Third  Edi- 

tion, revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.      By  Louis  Leroy,  M.  D.     Second  edition,  revised. 

With  95  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 
16 


Saunders'  Medical  Hand=Atlases. 


VOLUME^S  NOW  READY. 

ATLAS    AND    EPITOME    OF    INTERNAL    MEDICINE    AND 
CLINICAL   DIAGNOSIS. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  AUGUSTUS  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  179 
colored  figures  on  68  plates,  64  text-iliustrations,  259  pages  of  text.  Cloth, 
$3.00  net. 

ATLAS  OF  LEGAL  MEDICINE. 

By  Dk.  E.  R.  von  Hoffman,  of  Vienna.  Edited  by  Fredf.rick  Petf.r- 
SON,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians  and 
Surgeons,  New  Yorlc.  With  120  colored  figures  on  56  plates  and  193  beau- 
tiful half-tone  illustrations.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX. 

By  Dr.  L.  GrOnwald,  of  Munich.  Edited  by  Charles  P.  GRAYSON, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text- 
illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

ATLAS  AND    EPITOME  OF  OPERATIVE   SURGERY.     Second 

Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J.  CHAL- 
MERS DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical 
Surgery,  Jefferson  Medical  College,  Philadelphia.  With  40  colored  plates, 
278  text-illustrations,  and  410  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  SYPHILIS  AND  THE  VENEREAL 

DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  L. 
Bolton  B.\NGS,  M.  D..  Professor  of  Genito-Urinary  Surgery,  University 
and  Bellevue  Hospital  Medical  College,  New  York.  With  71  colored  plates, 
16  text-illustrations,  and  122  pages  of  text.     Cloth,  ;?3.So  net. 

ATLAS  AND  EPITOME  OF  EXTERNAL  DIS.  OF  THE  EYE. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With 
76  colored  illustrations  on  40 "plates  and  228  pages  of  text.     Cloth,  ^S-oo  net. 

ATLAS  AND  EPITOME  OF  SKIN  DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON.  M.D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  $3.50  net. 

ATLAS  AND   EPITOME  OF  SPECIAL  PATHOLOGICAL  HIS- 
TOLOGY. 

By  Dr.  H.  DCrck,  of  Munich.  Edited  by  LUDVIG  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tract, 
120  colored  figures  t>n  62  plates,  158  pages  of  text.  Part  H.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones.  123  colored  figures  on  60  pl.ites,  192  pages  of  text.  Per 
volume:  Cloth,  $3.00  net. 

17 


Saunders'  Medical  Hand= Atlases. 

VOLUMES  JUST  ISSUED. 

ATLAS  AND  EPITOME  OF  DISEASES  CAUSED   BY    ACCI- 
DENTS. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce 
Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Corrections  and 
to  the  Ahnshouse  and  Incurable  Hospitals,  New  York.  With  40  colored 
plates,  143  text-illustrations,  and  600  pages  of  text.     Cloth,  ^4.00  net. 

ATLAS  AND  EPITOME  OF  GYNECOLOGY. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  additions,  by  RICHARD  C.  NORRIS,  .\.  M.,  M.  D., 
Gynecologist  to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  53-5°  net. 

ATLAS  AND  EPITOME  OF  THE  NERVOUS  SYSTEM  AND  ITS 
DISEASES. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Frorn  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  EDWARD  D. 
Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University 
and  Bellevue  Hospital  Medical  College,  N.  Y.  With  83  plates ;  copious 
text.     $3.50  net. 

ATLAS   AND  EPITOME  OF   LABOR  AND  OPERATIVE    0B= 
STETRICS. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and  En- 
larged German  Edition.  Edited,  with  additions,  by  J.  CLIFTON  Edgar, 
M.D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.     With  126  colored  illustrations.     ^2.00  net. 

ATLAS  AND  EPITOME  OF  OBSTETRICAL  DIAGNOSIS  AND 
TREATMENT. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  J.  CLIFTON  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.  72  colored  plates,  numerous  text-illustrations,  and  copious 
text.     $3.00  net. 

ATLAS  AND  EPITOME  OF  OPHTHALMOSCOPY  AND  OPH- 
THALMOSCOPIC DIAGNOSIS. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged  Ger- 
man Edition.  Edited,  with  additions,  by  G.  E.  DE  SCHWEINITZ,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  152  colored  figures  and  82  pages  of  text.     Cloth,  53-°o  net. 

ATLAS  AND  EPITOME  OF  BACTERIOLOGY. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  PROF. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  From  the 
Second  Revised  German  Edition.  Edited,  with  additions,  by  GEORGE  H. 
Weaver,  M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush 
Medical  College.  In  Two  Parts.  Part  I.,  consisting  of  632  colored  figures 
on  69  plates.  Part  II.,  consisting  of  511  pages  of  text,  illustrated.  Per 
Part :   Cloth,  ^2.50  net. 

18 


Saunders'  Medical  Hand= Atlases. 

VOLUMES   JUST    ISSUED. 

ATLAS  AND  EPITOME  OF  OTOLOGY. 

By  Dr.  Gustav  BrUhl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr.  A. 
Pulitzer,  of  Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith! 
M.  D.,  Clinical  Professor  of  Otology,  Jefferson  Medical  College,  Philadel- 
phia. 244  colored  figures  on  39  plates,  99  text-cuts,  and  292  pages  of  text. 
Cloth,  53-°o  ri'^t- 

ATLAS  AND  EPITOME  OF  ABDOMINAL  HERNIAS. 

By  Privatdocent  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with 
additions,  by  WILLIAM  B.  CoLEY,  Clinical  Lecturer  on  Surgery,  Columbia 
University  (College  of  Physicians  and  Surgeons),  New  York  ;  Surgeon  to 
the  General  Memorial  Hospital,  New  York.  With  43  colored  figures  on 
36  plates,  100  text-cuts,  and  about  275,  pages  of  text.     Cloth,  $0.00  net. 

ATLAS  AND  EPITOME  OF  FRACTURES  AND   LUXATIONS. 

By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with  additions,  by 
Joseph  C.  Bloodgood,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  With  215  colored  figures  on  72  plates,  144  te.\t-cuts,  42  skia- 
graphs, and  over  300  pages  of  text.     Cloth,  $6.00  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  MOUTH,  THROAT, 
AND  NOSE. 

By  Dr.  L.  Grunwald,  of  Munich.  From  the  Second  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  jAMES  E.  Newcomb,  M.  D., 
Clinical  Instructor  in  Laryngology,  Cornell "  University  Medical  School. 
With  42  colored  figures,  39  text-cuts,  and  225  pages  of  text. 

ATLAS  AND  EPITOME  OF  NORMAL  HISTOLOGY. 

By  Privatdocent  Dr.  J.  Sobotta,  of  WUrzburg.  Edited,  with  additions, 
by  G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
the  Histological  Laboratory,  University  of  Michigan.  With  80  colored 
figures  and  68  text-cuts  from  the  orig;inal  of  W.  Freytag,  and  275  pages 
of  text. 

ATLAS  AND  EPITOME  OF  OPERATIVE  GYNECOLOGY. 

By  Dr.  Oskar  SchAeffer,  Privatdocent  in  the  University  of  Heidelberg. 
With  42  colored  figures  and  21  text-cuts  from  the  original  of  A.  Schmitson, 
and  125  pages  of  text. 

SAUNDERS*  MEDICAL  HANDATLASES. 

Three  years  ago  Mr.  Saunders  contracted  for  100,000  copies  of  the  twenty- 
six  volumes  that  are  to  compose  this  series  of  books.  Of  these  twenty-six  vol- 
umes only  eighteen  have  appeared,  and  .yet  over 

80,000   Copies 

have  already  been  imported.  Basing  the  sales  of  future  numbers  on  those 
already  issued,  the  prospects  are  that  the  ultimate  sale  of  these  volumes  will 
more  than  double  the  figures  originally  set. 


ADDITIONAL  VOLUMES  IN  PREPARATION. 
19 


Nothnagel's  Encyclopedia 

OF 

PRACTICAL    MEDICINE. 

AMERICAN  EDITION. 
Edited  by  ALFRED  STENGEL,  M.  D., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine ; 
and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Pathologie  und 
Therapie  "  is  conceded  by  scholars  to  be  without  question  the  best  System  of  Medicine 
in  existence.  So  necessary  is  this  book  in  the  study  of  Internal  Medicine  that  it  comes 
largely  to  this  country  in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B. 
Saunders  &  Company  have  arranged  with  the  publishers  to  issue  at  once  an  authorized 
American  edition  of  this  great  encyclopedia  of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part  of  this 
excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs  of  the  practical 
physician,  will  be  published.  These  volumes  will  contain  the  real  essence  of  the  entire 
work,  and  the  purchaser  will  therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  origi- 
nal.    Later  the  special  and  more  strictly  scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist  on  the  subject  to 
which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to  date,  and  the  American  edition 
will  be  more  than  a  mere  translation  of  the  German  ;  for,  in  addition  to  the  matter  contained 
in  the  original,  it  will  represent  the  very  latest  views  of  the  leading  American  and 
English  specialists  in  the  various  departments  of  Internal  Medicine.  The  whole  System 
■will  be  under  the  editorial  supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subjectr 
for  the  American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended  over  a 
number  of  years,  but  five  or  six  volumes  will  be  issued  dunng  the  coming  year,  and  the 
remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume  will  be  revised  to  the 
date  of  its  publication  by  the  eminent  editor.  This  will  obviate  the  objection  that  has 
heretofore  existed  to  systems  published  in  a  number  of  volumes,  since  the  subscriber  will 
receive  the  completed  work  while  the  earlier  volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been  to  compel 
physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases  to  be  undesirable. 
Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be  given  the  opportunity  of 
subscribing  for  the  entire  System  at  one  time;  but  any  single  volume  or  any  number  of 
volumes  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This  latter 
method,  while  not  so  profitable  to  the  publishers,  offers  to  the  purchaser  many  advan- 
tages which  will  be  appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work 
at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question,  form  the 
greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  confident  that  it 
will  meet  with  general  favor  in  the  medical  profession. 

20 


NOTHNAGEL'S  ENCYCLOPEDIA. 

AMERICAN  EDITION. 

VOLUMES  JUST  ISSUED  AND  IN  PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor,  'William  Osier,  M.D.,  F.R.C.P.,  Professor  of  the  Principles  and  Practice 
of  Medicine  in  Johns  Hopkins  University,  Baltimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  J5.00  net ;  Half 
Morocco,  J6.00  net.    Just  Ready. 

VARIOLA  (including  VACCINATION).  By  Dr.  H.  Immermann,  of  Basle. 
VARICELLA,  By  Dr.  Th.  von  Jukgknsen,  of  Tubingen.  CHOLERA 
ASIATICA  and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeister,  of 
Tubingen.  ERYSIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of 
Hamburg.  PERTUSSIS  and  HAY-FEVER.  By  Dr.  G.  Sticker,  of  Giessen. 
Editor,  Sir  J.  W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of 
Medicine,  Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illus- 
trated.    Cloth,  ;^5.oo  net  ;   Half  Morocco,  g6.oo  net.    Just  Ready. 

DIPHTHERIA.     By  the  editor.    Measles,  Scarlet  Fever,  Rothcln.    By  Dr.  Th.  von 

Jurgensen,  of  Tiibingen. 

Editor.  William  P.  Northrup,  M.  D.,  Professor  of  Pediatrics.  University  and  Belle- 
vue  Medical  College,  N.  Y.  Handsome  octavo,  672  pages,  illustrated,  including  24 
full-page  plates,  3  in  colors.     Cloth,  Js.oo  net ;  Half  Morocco,  J6.00  net.    Just  Ready. 

DISEASES  OF  THE  BRONCHL  By  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Rosenbach,  of  Berlin.  PNEU- 
MONIA.    By  Dr.  E.  Aufkecht,  of   Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  Js. 00 
net ;  Half  Morocco,  |6.oo  net.    Just  Ready. 

DISEASES  OF  THE  LIVER.  By  Drs.  H.  Quincke  and  G.  Hoppe-Sryler,  of 
Kiel.  DISEASES  OF  THE  PANCREAS.  By  Dr.  L.  Oser,  of  Vienna.  DIS- 
EASES OF  THE  SUPRARENALS.  By  Dr.  E.  Neusser,  of  Vienna. 
Editors,  Frederick  A.  Packard,  M.  D.,  Physician  to  the  Penna.  and  the  Children's 
Hospitals,  Phila. :  and  Reginald  H.  FitZ,  A.  M.,  M.  D.,  Hersey  Prof,  of  the  Theory 
and  Practice  of  Physic.  Harvard  Univ.  Handsome  octavo,  700  pages,  illustrated. 
Cloth,  ;j5.oo  net ;   Half  Morocco,  $6.00  net.     Jiist  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne.  MALA- 
RIAL DISEASES.     By  Dr.  J.  Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired;  Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine. 
Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,  PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.    By 

Dr.  p.  Ehklich,  of  Frankfort-on-the-Main,  Dk.  A.  Lazarus,  of  Charlottenburg,  and 
Dr.  Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of 
Frankfort-on-the-Main. 

Editor,  Alfred  Stengel,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.    Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE  GENERAL  MILIARY  TUBERCULOSIS. 

By  Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.     Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Charles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo,  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  By  Dr.  Hermann 
Nothnagel,  of  Vienna. 

Editor,  Humphry  D.  RoIIeston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on 
Pathology  at  St.  George's  Hospital,  London.  Handsome  octavo,  800  pages,  finely 
illustrated. 

21 


CLASSIFIED    LIST 

OF   THE 

MEDICAL    PUBLICATIONS 


W.  B  Saunders  &  Company. 


ANATOMY,  EMBRYOLOGY,  HIS- 
TOLOGY. 

Bbhm,  Davidoff,  and  Huber — A  Text- 
Book  of  Histology, 4 

Clarbson^A  Text-Book  of  Histology,  .  5 
Haynes — A  Manual  of  Anatomy,  ...  8 
Heisler — .'V  Text-Book  of  Embryology,  8 
Leroy — Essentials  of  Histology,  ....  16 
McClellan — Anatomy    in    Relation    to 

Art ;  Regional  Anatomy, 10 

Nancrede — Essentials  of  Anatomy,  .  .  16 
Nancrede— Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,    ...    11 
Sabotta — Atlas  of  Normal  Histology,   .   19 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,    ...  16 

Eyre — Bacteriologic  Technique 7 

Frothinghatn — Laboratory  Guide,    .   .  7 

Gorham — Laboratory  Bacteriology,  .  .  7 
Lehmann    and    Neumann — Atlas    of 

Bacteriologj', 18 

Levy  and  Klemperer's  Clinical  Bacte- 
riology,    10 

Mallory    and     Wright — Pathological 

Technique, 10 

McFarland — Pathogenic  Bacteria,    .   .  11 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,  ....  8 

Keen — Operation  Blank, 9 

Laine — Temperature  Chart, lo 

Meigs — Feeding  in  Early  Infancy,  ...  11 

Starr — Diets  for  Infants  and  Children,  .  13 

Thomas — Diet- Lists, 14 

CHEMISTRY  AND  PHYSICS. 

Brockway — Ess.  of  Medical  Physics,  .  16 
lelliffe  and  Diekman — Chemistry,    .    .     9 

'wolf — Examination  of  Urine 15 

Wolff— Essentials  of  Medical  Chemistry,   16 

CHILDREN. 

American  Text-Book  Dis.  Children,   .  i 

Griffith— Care  of  the  Baby, 8 

Griffith— Infant's  Weight  Charf,     ...  8 

Meigs — Feeding  in  Early  Infancy,  ...  11 

Powell — Essentials  of  Dis.  of  Children,  16 

Starr- Diets  for  Infants  and  Children,  .  13 

DIAGNOSIS. 
Cohen  and  Eshner — Essentials  of  Diag- 
nosis,   16 

Corwin — Physical  Diagnosis, 5 

Vierordt — Medical  Diagnosis, 15 

DICTIONARIES. 

The  American  Illustrated  Medical 
Dictionary, 3 

The  American  Pocket  Medical  Dic- 
tionary,   3 

Morton — Nurses'  Dictionary, 11 


EYE,  EAR,  NOSE,  AND  THROAT. 
An  American  Text-Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,     .      i 
Briihl  and  Politzer — Atlas  of  Otology,    19 
De  Schweinitz — Diseases  of  the  Eye,  .     6 
Friedrich  and  Curtis— Rhinology,  Lar- 
yngology-, and  Otology, 7 

Gleason — Essentials  of  the  Ear,  ....  16 
Gleason — Essentials  of  Nose  and  Throat,  16 
Gradle — Nose,  Pharj-nx,  and  Ear,  ...  7 
Griin'wald — Atlas    of   Mouth,   Throat, 

and  Nose, 19 

Griinwald — Atlas  of  Dis.  of  Larj'nx,  .  17 
Haab — Atlas  of  External  Dis.  of  Eye,  .  17 
Haab — Atlas  of  Ophthalmology,  ....  18 
Jackson — Manual  of  Diseases  of  the  Eye,  9 
Jackson — Essentials  Diseases  of  Eye,  .  16 
Kyle — Diseases  of  the  Nose  and  Throat,     9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    16 

Mracek — Atlas  of  Syphilis  and  the  Ven- 
ereal Diseases, 17 

Saundby — Renal  and  Urinary  Diseases,    13 

Senn — Genito-Urinary  Tuberculosis,  .    .    13 

Vecki — Sexual  Impotence 15 

GYNECOLOGY. 
American  Text-Book  of  Gynecology, 
Cragin — Essentials  of  Gynecology,     .    .    16 
Garrigues — Diseases  of  Women,        .   .      7 
Long — Syllabus  of  Gynecology,  . 
Penrose — Diseases  of  Women,     . 
SchaefTer — Atlas  of  Gynecology, 
Schaeffer — Atlas  of  Oper.  Gynecology,    19 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,   4 

Bergey — Principles  of  Hygiene,  ....  4 
Pyle — Personal  Hygiene, 12 

MATERIA     MEDICA,     PHARMA- 
COLOGY, and  THERAPEUTICS. 
An  American   Text-Book  of  Applied 

Therapeutics, i 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics,  and  Pharmacology,  .  .  5 
Morris — Ess.  of  M.M.  and  Therapeutics,  16 
Saunders'  Pocket  Medical  Formularj-,  12 
Sayre — Essentials  of  Pharmacy,  ....  16 
Sollmann — Text-Book  of  Pharmacology,  13 
Stevens — Modern  Therapeutics, ....  14 
Stoney — Materia  Medica  for  Nurses,  .  .  14 
Thornton— Prescription-Writing,    ...    15 


22 


MEDIC  A  L  PLBLICA  TIONS. 


23 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY, 

Chapman — Medical  Jurisprudence  and 
Toxicology, 5 

Crothers — Morphinism 6 

Golebiewski — Atlas  of  Diseases  Caused 
by  Accidents, 18 

Hofmann — Atlas  of  Legal  Medicine,  .    .    17 

NERVOUS  AND  MENTAL  DIS- 
EASES. ETC. 

Brower — Manual  of  Insanity, 5 

Chapin — Compendium  of  Insanity,  .  .  5 
Church  and  Peterson — Nervous   and 

Mental   Diseases, ....  5 

Jakob — Atlas  of  Nervous  System,  ...  18 
Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 16 

NURSING. 
Davis — Obstetric  and  Gynecologic  Nurs- 
ing,   6 

Griffith— The  Care  of  the  Baby,  ....  8 
Meigs — Feeding  in  Early  Infancy,  ...    11 

Morten — Nurses'  Dictionary, ii 

Stoney — Materia  Medica  for  Nurses,  .  14 
Stoney — Practical  Points  in  Nursing,  .  14 
Stoney — Surgical  Technique  for  Nurses,  14 
'Watson — Handbook  for  Nurses,     ...    15 

OBSTETRICS. 
An  American  Text-Book  of  Obstetrics,     2 
Ashton — Essentials  of  Obstetrics,   ...    16 
Boisliniere — Obstetric  Accidents, 
Dorland — Modern  Obstetrics,  .   . 
Hirst — Text-Book  of  Obstetrics,  . 
Norris — Syllabus  of  Obstetrics,    . 
SchaefTer — Atlas  Labor  and  Oper.  Obs 
Schaeffer— Atlas   of  Obstetrical   Diag 
nosis  and  Treatment, 18 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    2 

Durck — Atlas  of  Pathologic   Histologj',  17  ' 

Kalteyer — Essentials  of  Pathology,  .  .  i6 
Mallory    and    'Wright — Pathological 

Technique, \o 

Senn — Pathology  and    Surgical   Treat-        j 

ment  of  Tumors, 13  j 

Stengel — Text-Book  of  Pathology,    .   .  14  ' 

Stengel  and  W^hite— Blood, 14  ! 

Warren — Surgical  Pathology, 15 

PHYSIOLOGY. 

American  Text-Book  of  Physiology,  .  2 

Raynnond — Text-Book  of  Physiology,  .  12 

Stewart — Manual  of  Physiology,    ...  14 

PRACTICE  OF  MEDICINE. 
American  Text-Book  of  Theory  &  Prac.    3 
An  American  Year-Book  of  Xledicine 

and  Surgery, 3 

Anders — Practice  of  Medicine, 4 

Eichhorst — Practice  of  Medicine,  ...  6 
Lockwood — Practice  of  Medicine,  ...  10 
Morris — Ess.  of  Practice  of  Medicine,  .  16 
Nothnagel's  Encyclopedia,  ....  20,  21 
Salinger  &  Kalteyer — Mod.  Medicine,  12 
Stevens — Practice  of  Medicine,  ....    14 


SKIN  AND  VENEREAL. 
An  American    Text-Book  of   Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery— SyphiHs  and 

the  Venereal  Diseases, .8 

Martin — Essentials   of    Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .  .  16 
Mracek- Atlas  of  Diseases  of  the  Skin,  17 
Stelwagon— Diseases  of  the  Skin,  ...  13 
Stelwagon— Ess.  of  Diseases  of  Skin,  .    16 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  2 
An  Arnerican  Year-Book  of  Medicine 

and  Surgery, 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,  .  .  4 
DaCosta — Manual  of  Surgery,  ....  6 
Grant — Surgical  Disease  of  Face,  Mouth, 

and  Jaws, 8 

Helferich — .Atlas  of  Fractures,  ....  19 
International  Text-Book  of  Surgery,  .     9 

Keen — Operation  Blank g 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 9 

Macdonald— Surgical     Diagnosis     and 

Treatment, 10 

Martin — Essentials   of  Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .  .  16 
Martin— Essentials  of  Surgery,     ....    16 

Moore — Orthopedic  Surgery, n 

Nancrede — Principles  of  Surgery,  .  .  11 
Pye — Bandaging  and  Surgical  Dressing,  la 
Scudder — 'I'reatment  of  Fractures,  ...  13 
Senn — Genito-Urinary  Tuberculosis,  .   .   13 

Senn — Practical  Surgery, 13 

Senn— Syllabus  of  Surgery, 13 

Senn — Pathology   and    Surgical   Treat- 
ment of  Tumors, 13 

Sultan — Atlas  of  Abdominal  Hernias,     .    19 
Warren — Surgical  Pathology  and  Ther- 
apeutics,      15 

Zuckerkandl — Atlas  of  Operative  Sur- 
gery,     17 

URINE  AND  URINARY  DISEASES. 
Ogden — Clinical  Examination  of  Urine,  11 
Saundby — Renal  and  Urinary  Diseases,  12 
Wolf — Handbook  of  Urine  Examination,  15 
Wolff — Ess.  of  Examination  of  Urine,  .    16 

MISCELLANEOUS. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,    4 

Bastin — Laboratory  Exercises  in  Botany,   4 
Galbraith — The   Four  Epochs  of  Wo- 
man's Life, 7 

Golebiewski — Atlas  of  Diseases  Caused 

by  Accidents, 18 

Gould  and  Pyle — .Anomalies  and  Curi- 
osities of  Medicine, 7 

Grafstrom — .Massage, 8 

Keating — Life  Insurance, 9 

Pyle — A  Manual  of  Personal  Hygiene,  .  12 

Robson  &  Moynihan — Dis.  of  Pancreas,  12 
Saunders'  Medical  Hand-.Atlases,  17,  18, 19 

Saunders'  Pocket  Medical  Formulary,  .  12 

Saunders'  CJuestion-Compends,  ....  16 
Stewart  and  Lawrance — Essentials  of 

Medical  Electricity, 16 

Warwick  and  Tunstall— First  Aid,  .   .  15 


Date  Due 


ATLASES 


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SAUNDERS^  MEDICAL  HAND-ATLASES 


u  -7^ 


M939a 
1898 

Mracke,  Franz 

Atlas  of  syphilis  and  the 

venereal  diseases... 


Atlas  and  Epitome  of  Labor  and  Open  "^  ^'"^"^  "^°'°''*^  ^'^"^^^  '^''''"' 

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ol  Heidelberg.  From  the  ^iecoiid  Revised  and  Enlarged  German  Edition  Kdited' 
with  additions,  by  J.  C.  Eugak,  M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery' 
Cornell  University  Medical  School.  With  122  colored  figures  on  56  plates  38  other  illus 
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hditcd,  with  additions,  by  h     '^    ^-' ..    »^     ..     -  

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pages  of  text.  WV^J.  I 

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the  nervous  tissues  as  found 

Atlas  and  Epitome  of  Ophl 

O.  IIaab, of  Zurich.    2' 
with  additions,  by  G. 
Medical  College,  PW 
'■  Nowhere  else  can 
eye-fundus  as  this  vl 

Atlas  of   BacterioU 

Pkoi-.  Dk.  K.  15.  L 
Realised  and  Enlal 
M.  U.,  Assistant    H 
Chicago.     Two 
of  text,  illustrat 

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of  Phof.  Dk.  a 

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Atlas  and  Epit( . 

of  Gottingen.     1 

gery,  Columbia 

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Atlas  and  Epiti 

Helff.kich,  of 

ciate  in  Surger 

lithographic  ph 

Such  a  splendid 

represent  time. 
Atlas  and  Epito 

of  Munich.     />' 

additions,  by  J 

University  Mec 

Jn  Press. 

Atlas  and  Epit 

Wiirzburg.     Ed 
.\natomy  and 
80  colored  figur 

Atlas  and  Epit< 

docent  at  the  U 
the  original  of  . 


Philada. 


in 


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VfClT 

M939a 

1898 
Mracke,  Franz 

Atlas  of  syphilis  and  the  venereal 
diseases. •• 


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